Therapeutic regimen and methods for treating or ameliorating visual disorders associated with an endogenous retinoid deficiency

ABSTRACT

Disclosed herein are therapeutic regimens for treating or ameliorating a visual disorder associate with an endogenous retinoid deficiency in a subject by administering a therapeutically effective amount of a synthetic retinal derivative or a pharmaceutically acceptable composition comprising a synthetic retinal derivative according to the therapeutic regimen which leads to local recovery of visual functions such as visual fields, visual acuity and retinal sensitivity, among others.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional PatentApplication No. 61/325,763, filed Apr. 19, 2010, U.S. Provisional PatentApplication No. 61/407,436 filed Oct. 27, 2010, and U.S. ProvisionalPatent Application 61/447,611 filed Feb. 28, 2011, the disclosures ofwhich are incorporated herein by reference for all purposes.

FIELD OF THE INVENTION

This invention is directed to therapeutic regimens and methods fortreating visual disorders associated with an endogenous retinoiddeficiency in a subject by administering a synthetic retinal derivativeto the subject, wherein the therapeutic regimens and methods result inimprovements in the subject's visual function.

BACKGROUND OF THE INVENTION

Retinal deficiencies disrupt or interfere with the production,conversion and/or regeneration of 11-cis-retinal, which is a key VitaminA derivative in the retinoid or visual cycle. 11-Cis-retinal is anendogenous retinoid produced in and by the retinal pigment epithelium(RPE) from the isomerization and oxidation of the all-trans-retinol(Vitamin A derived from the diet). 11-Cis-retinal functions as achromophore and covalently binds to the protein opsin to form rhodopsin.Vision is initiated when a light photon is captured by 11-cis-retinal,resulting in the isomerization to all-trans-retinal and disassociationfrom opsin. Vision is sustained by the cycling of all-trans-retinal backinto 11-cis-retinal, which occurs by a complex series of biochemicalreactions involving multiple enzymes and proteins in the retinoid orvisual cycle.

Endogenous retinoid deficiencies, such as those caused by mutations inthe genes encoding the enzymes and proteins utilized in the visual cycleor those caused by the aging process, impair the synthesis of11-cis-retinal, the result of which leads to visual disorders due to theshortage or depletion of 11-cis-retinal.

For example, Leber congenital amaurosis (LCA), a cause of inheritedchildhood blindness that affects children from birth or shortlythereafter, is associated with an inherited gene mutation in the RPE65gene which encodes the protein retinal pigment epithelial protein 65(RPE65) and/or an inherited gene mutation in the LRAT gene which encodesthe enzyme lecithin:retinol acetyltransferase (LRAT). RPE65 and LRAT areboth critical for the visual cycle. Patients with LCA lack the abilityto generate 11-cis-retinal in adequate quantities and therefore sufferfrom severe vision loss at birth, nystagmus, poor pupillary responsesand severely diminished electroretinograms (ERGs).

Mutations in the LRAT or RPE65 genes are also associated with autosomalrecessive retinitis pigmentosa (arRP), which is a subset of hereditaryretinitis pigmentosa (RP) which is characterized by degeneration of rodand cone photoreceptors. Patients with arRP may lose vision either inchildhood or in mid-life. The classic pattern of vision loss includesdifficulties with dark adaptation and night blindness in adolescence andloss of mid-peripheral visual field in young adulthood. arRP typicallypresents itself as primary rod degeneration with secondary degenerationof cones and is thus described as a rod-cone dystrophy, with rods beingmore affected than cones. This sequence of the photoreceptor cellsinvolvement explains why arRP patients initially exhibit nightblindness, and only in later life become visually impaired in diurnalconditions (Hamel C., Orphanet Journal of Rare Diseases I:40 (2006)).arRP is the diagnosis given to patients with photoreceptor degenerationwho have good central vision within the first decade of life, althougharRP onset can also occur much later at either the beginning of mid-lifeor after mid-life (“late onset arRP”). As the disease progresses,patients lose far peripheral vision, eventually develop tunnel vision,and finally lose central vision by the age of 60 years.

Retinitis Punctata Albesciens is another form of Retinitis Pigmentosathat exhibits a shortage of 11-cis-retinal in the rods. Aging also leadsto the decrease in night vision and loss of contrast sensitivity due toa shorting of 11-cis retinal. Excess unbound opsin is believed torandomly excite the visual transduction system. This can create noise inthe system, and thus more light and more contrast is necessary to seewell.

Congenital Stationary Night Blindness (CSNB) and Fundus Albipunctatusare a group of diseases that are manifested as night blindness, butthere is not a progressive loss of vision as in the RetinitisPigmentosa. Some forms of CSNB are due to a delay in the recycling of11-cis-retinal. Fundus Albipunctatus until recently was thought to be aspecial case of CSNB where the retinal appearance is abnormal withhundreds of small white dots appearing in the retina. It has been shownrecently that this is also a progressive disease although much slowerthan Retinitis Pigmentosa. It is caused by a gene defect that leads to adelay in the cycling of 11-cis-retinal.

Endogenous retinoid deficiencies can also be associated with the agingprocess, even in the absence of inherited gene mutations of the genesencoding the enzymes and proteins utilized in the visual cycle.Age-related visual disorders include, for example, loss of night vision,nyctalopia and contrast sensitivity due to a shortage of 11-cis-retinal.This is consistent with the finding that a dramatic slowing ofrod-mediated dark adaptation after light exposure associated with humanaging is related to a delayed regeneration of rhodopsin (Jackson, G. R.et al., J. Vision Research 39, 3975-3982 (1999)). In addition, excessunbound opsin (due to 11-cis-retinal shortage) is believed to randomlyexcite the visual transduction system. This can create noise in thesystem, and thus necessitates more light and/or more contrast in orderto see well.

The use of synthetic retinal derivatives and compositions thereof inmethods of restoring or stabilizing photoreceptor function in avertebrate visual system and in methods of treating age-related retinaldysfunction is disclosed in International Published Patent ApplicationNos. WO 2004/082622, WO 2006/002097, and WO 2011/034551, and PublishedU.S. Application Nos. 2004/0242704 and 2010/0035986. A study to evaluatethe effects of daily and intermittent dosing of 9-cis-retinyl acetate, asynthetic retinal derivative, in RPE65−/− mice is disclosed in Maeda, T.et al., Investigative Ophthalmology & Visual Science (2009), Vol. 50,No. 9, pp. 4368-4378).

Animal models have shown that synthetic retinoids which are highly-lightsensitive compounds are photoisomerized or “bleached” by light from theretina within just a few hours unless the eyes are covered. Thesestudies were conducted with the animals kept in the dark during andfollowing treatment with synthetic retinoids until the evaluation periodin order to minimize photoisomerization/bleaching of the syntheticretinoid. Batten M L et al. “Pharmacological and rAAV Gene TherapyRescue of Viscual Functions in a Blind Mouse Model of Leber CongenitalAmaurosis” PLo-S Medicine vol. 2, p. 333 (2005); Margaron, P., Castaner,L., and Narfstrom, K. “Evaluation of Intravitreal cis-RetinoidReplacement Therapy in a Canine Model Of Leber's Congenital Amaurosis”Invest Ophthalmol Vis Sci 2009; 50:E-Abstract 6280; Gearhart P M,Gearhart C, Thompson D A, Petersen-Jones S M. “Improvement of visualperformance with intravitreal administration of 9-cis-retinal inRpe65-mutant dogs” Arch Ophthalmol 2010; 128(11): 1442-8.

Frequent administration of any retinoid to compensate for the bleachingeffect implicates the well known toxicity of the retinoid class of thecompounds. See, Teelmann, K “Retinoids: Toxicity and Teratogenicity toDate,” Pharmac. Ther., Vol. 40, pp 29-43 (1989); Gerber, L E et al“Changes in Lipid Metabolism During Retinoid Administration” J. Amer.Acad. Derm., Vol. 6, pp 664-74 (1982); Allen L H “Estimating thePotential for Vit A Toxicity in Women and Young Children” J. Nutr., Vol.132, pp. 2907-19 (2002); Silverman, A K “Hypervitaminosis A Syndrome: AParadigm of Retinoid Side Effects”, J. Am. Acad. Derm., Vol. 16, pp1027-39 (1987); Zech L A et al. “Changes in Plasma Cholesterol andTriglyceride Levels After Treatment with Oral Isotretinoin” Arch.Dermatol., Vol. 119, pp 987-93 (1983). Toxicity caused by chronicadministration of retinoids can cause changes in lipid metabolism,damage to the liver, nausea, vomiting, blurred vision, damage to bones,interference with bone development and several other serious undesirableeffects.

In the context of treating the loss or impairment of vision due toretinoid deficiency, which is a chronic condition requiring lifetimetreatments, these toxic effects can be very important. These sideeffects are of particular concern in young patients, whosesusceptibility to side effects related to their physical development iswell documented.

This combination of a need for repeated administration in response tobleaching, and the undesirable serious side effects of repeatedadministration, poses a problem for the use of synthetic retinoids totreat the loss of vision caused by retinoid deficiency. A recent studyevaluated the usefulness of retinoids as a treatment for these disordersand concluded that retinoids and similar compounds are simply not goodclinical candidates for the treatment of retinoid deficiency disorders.See, Fan J. et al. “Light Prevents Exogenous 11-cis Retinal fromMaintaining Cone Photoreceptors in Chromophore-deficient Mice”, Invest.Ophthalmol. Vis Sci. Jan. 12, 2011, 10-6437.

It has now been discovered that by use of certain dosing regimens ofsynthetic retinal derivatives, it is possible to produce meaningfulimprovement or recovery of vision that is long lasting, while chronictoxic effects can be greatly reduced or even eliminated. This wascompletely unexpected, and indeed is completely contrary to theexpectation of the art.

SUMMARY OF THE INVENTION

The present invention is directed to therapeutic regimens and methodsfor treating or ameliorating visual disorders associated with anendogenous retinoid deficiency in a subject, wherein the method andtherapeutic regimen comprises the following sequential steps:

a) Administering to the subject a first dose of a first therapeuticallyeffective amount of a synthetic retinal derivative or a firsttherapeutic effective amount of a pharmaceutically acceptablecomposition comprising a synthetic retinal derivative that provides forreplacement of endogenously produced 11-cis-retinal;

b) commencing a resting period of at least one month during which asynthetic retinal derivative is not administered to the subject;

c) administering to the subject a second therapeutically effectiveamount of the synthetic retinal derivative;

d) repeating steps a through c as needed.

The therapeutic regimen described above is characterized in that thesubject's visual function is meaningfully improved. This improvement isof a duration that is clinically useful and is not associated with toxiceffects that would prevent or limit its long term use.

This invention is also directed to kits comprising a therapeuticeffective amount of a synthetic retinal derivative or a therapeuticeffective amount of a pharmaceutically acceptable composition comprisinga synthetic retinal derivative and instructions for administering thesynthetic retinal derivative or the pharmaceutically acceptablecomposition to a subject according to the therapeutic regimen disclosedherein. Preferably, the kits are for use in the treatment oramelioration of a visual disorder associated with endogenous retinoiddeficiency in a subject.

The therapeutic regimens and methods of the invention maximize theefficacy of synthetic retinal derivatives or pharmaceutically acceptablecompositions comprising synthetic retinal derivatives when administeredto a subject while minimizing and/or managing the toxicity typicallyassociated with retinoic acid derivatives.

Specific embodiments of these aspects of the invention are described inmore detail below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1. Schematic drawing of the retinoid cycle.

FIG. 2. Seven Goldmann visual fields (GVF) from subject #1 (A-G). Usingthe V4e target, progressive widening of the visual fields is seen inboth eyes from screening (2A) to day 7 (2B), day 14 (2C), one month (2D)and four months (2E) after the initiation of 7 days of oral treatmentwith the composition of Example 1. Increased sensitivity to the smallertarget I4e is also seen (2E).

FIG. 3. Eight Goldmann visual fields (GVFs) for subject #3 (A-H). Atscreening a non-detectable visual field was found using the V4e target(3A), which improved to a small central island on day 3 (3B). Thiscentral island was reliably detected through one month post dosing (3E).

FIGS. 4A and 4B. Improvement in ETDRS/LogMAR/Snellen equivalent visualacuity during and after treatment in the right eye (OD) and left eye(OS) of subject #1 (FIG. 4A) and subject #2 (FIG. 4B). The left eye waspatched at all times for the 7 days of treatment except during scheduledvisual function tests. The patch was removed on Day 7.

FIG. 5. Improvement in ETDRS/LogMAR/Snellen equivalent visual actuityduring an after treatment in the right eye (OD) and left eye (OS) ofsubject #5 up to six months after dosing.

FIG. 6. Demographics and baseline visual acuities (VA) for elevensubjects with either Leber Congenital Amaurosis (LCA) or RetinitisPigmentosa (RP) due to mutations in either LRAT or RPE65 genes aslisted. Best VA change from baseline for each eye is reported with theassociated assessment date after treatment.

FIG. 7. Overall summary of best change in visual acuity (VA) frombaseline (ETDRS letter score) from Day 9 to Month 8 post dosing. Datahas been clustered based on Baseline VA category.

FIG. 8. ETDRS/LogMAR/Snellen equivalent visual acuity (VA) the elevensubjects of FIG. 6 after treatment with either 40 mg/m2 (40 mg) or 10mg/m2 (10 mg) of the Composition. Data represents the average letterscore for both eyes, with the exception of Subjects 4 and 11, both ofwhich demonstrated measurable letter scores for only one eye.

FIG. 9. AMA low vision grid analysis of the Goldmann visual fields (GVF)for Subjects 1-9. Analysis was performed of the GVFs observed witheither the small I4e target (FIG. 9A) or the larger V4e target (FIG. 9B)before and at Day 14.

FIG. 10. Average levels of Triglycerides, HDL, Cholesterol and LDL wereassessed through the 7 days of dosing with 10 mg/m2 or 40 mg/m2 of thecomposition of Example 1, and the following 7 days after treatment wascomplete. Elevations in triglyceride levels were observed, which weretransient and returning to baseline after treatment was completed. Atransient decrease in HDL levels was also observed. Effects on lipidmetabolism were more pronounced in the 40 mg/m2 treatment group.

DETAILED DESCRIPTION OF THE INVENTION

In one aspect, the present invention is directed to therapeutic regimensfor treating or ameliorating visual disorders in a subject, particularlyloss of visual functions, by the administration of a synthetic retinalderivative or a pharmaceutically acceptable composition comprising thesynthetic retinal derivative, which comprise first establishing abaseline of the subject's visual functions prior to administration, thenadministering a therapeutically effective amount of the syntheticretinal derivative or the pharmaceutically acceptable compositionthereof to the subject for an initial dosing period, during which thesubject's visual function improves as compared to the subject's baselineof visual function prior to administration, followed by a resting periodduring which no synthetic retinal derivative or pharmaceuticallyacceptable composition thereof is administered and the subject's visualfunctions continue to improve or the improvements in the subject'svisual functions obtained during the first dosing period are sustained,followed by a subsequent administration of the synthetic retinalderivative or a pharmaceutically acceptable composition thereof afterthe resting period. The resting period and subsequent administration ofthe synthetic retinal derivative or the pharmaceutically acceptablecomposition can be repeated as needed to maintain the improvement in thesubject's visual function achieved during the first dosing period orduring the resting period. Optionally, a determination may be madeduring the initial resting period as to whether a subsequent therapeuticeffective amount of the synthetic retinal derivative or thepharmaceutically acceptable composition thereof is to be administeredbased on the subject's visual function evaluated during the restingperiod.

In one embodiment, the baseline of the subject's visual function isestablished prior to the administration of the first therapeuticeffective dose of the synthetic retinal derivative or a pharmaceuticallyacceptable composition thereof by evaluating one or more of thesubject's visual field, visual acuity, ability to perform life tasks,retinal sensitivity, dynamic pupillary response, nystagmus, corticalvisual function, color vision or dark adaptation. In a furtherembodiment, the baseline of the subject's visual function is establishedby evaluating the subject's field of vision. In another embodiment, thebaseline of the subject's visual function is established by evaluatingthe subject's visual acuity. In another embodiment, the baseline isestablished by evaluating the subject's retinal sensitivity. In anotherembodiment, the baseline is established by evaluating the subject'svisual field, visual acuity and retinal sensitivity.

In another embodiment, establishing the subject's baseline of visualfunction comprises establishing a baseline of the subject's visualfield, the subject's visual acuity, the subject's retinal sensitivity,the subject's dynamic pupillary response, the subject's nystagmus, thesubject's cortical visual function, the subject's ability to performlife tasks, the subject's color vision and/or the subject's darkadaptation. Preferably, establishing the subject's baseline of visualfunction comprises establishing the baseline of the subject's visualfield, the subject's visual acuity, the subject's ability to performlife tasks, and the subject's retinal sensitivity by established tests.

In one embodiment, the subject's visual function rapidly improves duringthe first dosing period from the baseline of the subject's visualfunction established prior to administration of the first therapeuticeffective amount of the synthetic retinal derivative or thepharmaceutically acceptable composition thereof to the subject. Forpurposes of this invention, “rapidly” improves refers to aclinicallymeaningful improvement in a subject's visual functions as compared tothe baseline of the subject's visual functions in a period shorter thanthe first dosing period. Preferably, in one embodiment, the subject'svisual functions are significantly improved within three days, withintwo days, or within one day of the commencement of the first dosingperiod. In another embodiment, the subject's visual functions improveduring the first dosing period as compared to baseline, and continue toimprove after the completion of the first dosing period and intothefirst rest interval. In a further embodiment, the improvement in thesubject's visual function in the first dosing period comprises expandingthe subject's visual field as compared to the visual field baseline,improving the subject's visual acuity as compared to the visual acuitybaseline, and/or improving the subject's retinal sensitivity as comparedto the baseline retinal sensitivity.

In one embodiment, the improvement in the subject's visual functionduring the first dosing period comprises an expansion of the subject'svisual field as compared to the baseline.

In another embodiment, the improvement in the subject's visual functionin the initial resting period comprises an expansion of the subject'svisual field as compared to the expansion of the subject's visual fieldduring the first dosing period.

In another embodiment, the improvement in the subject's visual functionduring the first dosing period and/or the resting period comprises anexpansion of the subject's visual field temporally and/or nasally. Inone embodiment of the invention, the expansion of the subject's visualfield during the first dosing period is by at least 5 degrees or atleast 10 degrees nasally, and at least 20 degrees, or at least 30degrees or at least 40 degrees temporally.

In another embodiment, the improvement in the subject's visual functionin the first dosing period comprises an improvement in the subject'svisual acuity as compared to the baseline.

In another embodiment, the improvement in the subject's visual functionin the resting period comprises an improvement in the subject's visualacuity as compared to the improvement in the subject's visual acuityduring the first dosing period.

In another embodiment, the improvement in the subject's visual functionin the first dosing period comprises an improvement in the subject'sretinal sensitivity as compared to the baseline.

In another embodiment, the improvement in the subject's visual functionin the resting period comprises an improvement in the subject's retinalsensitivity as compared to the improvement in the subject's retinalsensitivity during the first dosing period.

In another embodiment, the improvement in the subject's visual functionin the resting period comprises an improvement in the subject's abilityto perform life tasks, as compared to the improvement in the subject'sretinal sensitivity during the first dosing period. In one embodiment,the resting period can be of any length of time from about one month orlonger. In other embodiments of the invention, the resting period isfrom about 1 month to about 1 year. The length of the resting periodwill be dependent upon the therapeutic effective amount of syntheticretinal derivative or the therapeutic effective amount of apharmaceutically acceptable composition comprising a retinal derivativeto be administered therein. The first resting period can be for about 1to 3 months. In one embodiment of this invention, the resting period isfrom one month to nine months in duration. In other embodiments, theresting period is from one to six months, or from three to six months.

In other embodiments of the invention, the resting period is not a fixedperiod. Instead, good clinical judgment may indicate that it ispreferable to wait until the visual improvement that the treatment hasproduced in the subject has begun to reverse or has reversed to asignificant degree before administering another dose of syntheticretinoid derivative. When later doses are administered in this way, theclinician will evaluate the subject's vision as needed and, in theexercise of good clinical judgment in light of the subject's overallhealth and vision, will determine when an additional dose of syntheticretinoid derivative is warranted. In any event, the additional doses ofsynthetic retinoid derivative will not be administered at intervalsshort enough to cause chronic retinoid toxicity.

In another embodiment, there is provided a method for the prophylaxis ortreatment of a subject having or at risk for developing a diminishedvisual capacity. The method generally includes determining whether thesubject has a deficient endogenous retinoid level or is at risk fordevelopment thereof, as compared with a standard subject, andadministering an effective amount of a synthetic retinal derivative or apharmaceutical composition thereof.

A therapeutically effective amount of the synthetic retinoid derivativeis typically in the range of from about 49 milligrams per square meterof body surface area (mg/m²) to about 840 mg/m². This amount can beadministered in a single dose, or as a divided dose over a period aslong as two weeks. The size of the dose, and the time over which thedivided dose is administered, will be determined in the exercise ofroutine good clinical judgment in light of the subject's overall health,the degree of vision loss or impairment, age, and other factors.

In some embodiments, the therapeutically effective amount of thesynthetic retinoid derivative is in the range of from about 70 to 525mg/m². In other embodiments, the therapeutically effective amount of thesynthetic retinoid derivative is in the range of from about 70 to 490mg/m². In other embodiments, the therapeutically effective amount of thesynthetic retinoid derivative is in the range of from about 70 to 420mg/m². Yet in other embodiments, the therapeutically effective amount ofthe synthetic retinoid derivative is in the range of from about 49 to280 mg/m². In some embodiments, the therapeutically effective amount ofthe synthetic retinoid derivative is in the range of from about 280 to490 mg/m². In yet other embodiments, the therapeutically effectiveamount of the synthetic retinoid derivative is in the range of fromabout 70 to 280 mg/m².

The above therapeutically effective amount can also be administered in adivided dose, for example over five days to fourteen days. In someembodiments, the above therapeutically effective amount can beadministered in a divided dose over seven to ten days. The divided doseis typically administered in equal daily amounts over the dosing period.

The therapeutically effective amount can be adjusted during the courseof treatment. In some embodiments, the amount of later doses is reducedfrom the amount of the initial dose. In other embodiments, the amount ofthe later doses is the same as the amount of the initial dose, while inother embodiments, the amount of the later dose may be increased fromthe amount of the initial dose. The size of the later doses, and thetime over which the divided dose is administered, will be determined inthe exercise of routine good clinical judgment in light of the subject'soverall health, the degree of vision loss or impairment, the degree ofimprovement in the subject's visual function, age, and other factors.

In one embodiment, the subject's loss of vision is due to a LRAT orRPE65 gene mutation. In one preferred embodiment of the invention, thesubject has a LRAT gene mutation. In another preferred embodiment of theinvention, the subject has a RPE65 gene mutation. In another preferredembodiment of the invention, the subject has a LRAT gene mutation and aRPE65 gene mutation.

In one embodiment, the subject has Leber congenital amaurosis (LCA),autosomal recessive retinitis pigmentosa (arRP), age-related retinaldysfunction, nyctalopia, retinitis punctata albesciens, congenitalstationary night blindness or fundus albipunctatus. In one preferredembodiment of the invention, the subject has LCA. In another preferredembodiment of the invention, the subject has arRP. In another preferredembodiment of the invention, the subject has age-related retinaldysfunction characterized by one or more of the following conditions: animpairment in rod-mediated dark adaptation after light exposure, animpairment in night vision, an impairment in contrast sensitivity, animpairment in visual field, an impairment in visual acuity andage-related macular degeneration (AMD).

In one embodiment, the subject is an adult.

In another embodiment, the subject is a pediatric patient, for example,an infant, a child or an adolescent.

In another embodiment, the patient is younger than 15 years old.Preferably, the subject has LCA and is younger than 15 years old.

In another embodiment, the subject is younger than 1 year. Preferably,the subject has LCA and is younger than 1 year old.

In another embodiment, the subject is 15 years old or older. Preferably,the subject has arRP and is at least 15 years old, preferably between 30and 40 years old.

In another embodiment, the subject is 5 years old or older.

In one embodiment, the first and any subsequent therapeutic effectiveamount is administered orally to the subject.

In another embodiment, the first and any subsequent therapeuticeffective amount is administered locally to the eyes of the subject.

In another embodiment, the first and any subsequent therapeuticeffective amount is administered topically to the eyes of the subject.

In another embodiment the first and any subsequent therapeutic effectiveamount is administered intraocularly.

In another embodiment, the first and any subsequent therapeuticeffective amount is administered subcutaneously.

The synthetic retinal derivative can be delivered by any pharmacologicvehicle in which it is stably delivered to the subject and effectivelyreleased upon administration. The pharmaceutical vehicle art is wellfamiliar with the chemistry of retinoids and the formulations ofpharmacologic vehicles for them. These known delivery vehicles includethose which have physical properties, chemical properties and releaserates that are suited to delivery synthetic retinal derivatives. Liquiddelivery vehicles, such as vegetable oils (including soybean, olive, andrapeseed or canola oils) can be used.

In one embodiment, the synthetic retinal derivative is selected from11-cis-retinyl acetate, 11-cis-retinyl succinate, 11-cis-retinylcitrate, 11-cis-retinyl ketoglutarate, 11-cis-retinyl fumarate,11-cis-retinyl malate or 11-cis-retinyl oxaloacetate. Preferably thesynthetic retinal derivation is 11-cis retinyl acetate.

Preferably, the 9-cis-retinyl ester is 9-cis-retinyl acetate or9-cis-retinyl succinate.

Another embodiment of this aspect is wherein the pharmaceuticallyacceptable composition further comprises a lipid vehicle.

Another embodiment of this aspect is wherein the pharmaceuticallyacceptable composition comprises a 9-cis-retinyl ester and soybean oil.

Another embodiment of this aspect is wherein the 9-cis-retinyl ester is9-cis-retinyl acetate.

Another embodiment of this aspect is wherein the subject has a LRAT orRPE65 mutation.

Another embodiment of this aspect is wherein the subject has Lebercongenital amaurosis, retinitis pigmentosa, age-related retinaldysfunction, nyctalopia, retinitis punctata albesciens, congenitalstationary night blindness or fundus albipunctatus.

Another embodiment is wherein the age-related retinal dysfunction ismanifested by one or more of the following clinical conditions: animpairment in rod-mediated dark adaptation after light exposure, animpairment in night vision, an impairment in contrast sensitivity, animpairment in visual field, an impairment in visual acuity andage-related macular degeneration (AMD).

Another embodiment of this aspect is wherein the synthetic retinalderivative or the pharmaceutically acceptable composition comprising thesynthetic retinal derivative is administered orally to the subject.

Another embodiment of this aspect is wherein the synthetic retinalderivative or the pharmaceutically acceptable composition comprising thesynthetic retinal derivative is administered locally to the eyes of thesubject.

Another embodiment of this aspect is wherein the synthetic retinalderivative or the pharmaceutically acceptable composition comprising thesynthetic retinal derivative is administered topically to the eyes ofthe subject.

Another embodiment of this aspect is wherein the synthetic retinalderivative or the pharmaceutically acceptable composition comprising thesynthetic retinal derivative is administered intraocularly.

Another embodiment of this aspect is wherein the synthetic retinalderivative or the pharmaceutically acceptable composition comprising thesynthetic retinal derivative is administered subcutaneously.

In one embodiment of the invention, the therapeutic regimen of theinvention is an administration regimen for treating a visual disorderassociate with endogenous retinoid deficiency in a subject.

Another aspect of the invention is the use of a synthetic retinalderivative in the preparation of a medicament for administration to asubject having an endogenous retinoid deficiency. Preferably, themedicament is administered to the subject by a therapeutic regimendisclosed herein.

Another aspect of the invention is directed to kits comprising atherapeutic effective amount of a synthetic retinal derivative or atherapeutic effective amount of a pharmaceutically acceptablecomposition comprising a synthetic retinal derivative and instructionsfor using the synthetic retinal derivative or a therapeutic effectiveamount of a pharmaceutically acceptable composition comprising asynthetic retinal derivative in a therapeutic regimen or method of theinvention for the treatment or amelioration of a visual disorderassociated with endogenous retinoid deficiency in a subject.

These and other embodiments of the invention are disclosed in moredetail herein.

Unless defined otherwise in the specification, the following terms andphrases shall have the following meanings:

As used herein, “visual disorders” refers broadly to disorders in thephotoreceptors, tissue or structures of the eye. Visual disordersinclude, but are not limited to, retinal degeneration, retinaldystrophy, loss of photoreceptor function, photoreceptor cell death andstructural abnormalities. For purposes of this invention, the phrase“visual disorders” refers to visual disorders associated with anendogenous retinoid deficiency. Visual disorders of the invention aretypically characterized by impaired or less than normal (includingcomplete loss of) visual functions in the subject, which include, forexample, poor visual acuity, low or lack of retinal sensitivity, narrowor undetectable visual fields, and the like.

“Therapeutically effective amount” refers to that amount of a compoundwhich, when administered to a subject, preferably a human, is sufficientto cause a clinically meaningful therapeutic effect.

The term “therapeutic effect” as used herein refers to the improvementor restoration of the vision of a patient, in one or both eyes of thepatient.

The loss of vision in patients with retinoid deficiency is typicallysevere, but can be present in degree and forms that vary from patient topatient. Patients can lose their peripheral vision, they can lose theirability to see in low to moderate light, their overall acuity candecline, or other vision loss can occur. This loss can be progressive(especially in adult onset case(s) of retinoid deficiency, such asretinitis pigmentosa) eventually leading to very little vision or tocomplete blindness. When not progressive (such as in CongenitalStationary Night Blindness) loss of vision can be severe, if not nearlycomplete, from the outset.

The type and extent of loss can be roughly correlated to the degree ofretinoid deficiency, affected cell type (e.g. rods or cones), and/orlocalization of the retinoid deficiency in the retina. Where thedeficiency effect is strongest at the periphery of the retina,peripheral vision losses can be seen earliest and most profoundly. Whenthe deficiency effect is more generalized throughout the retina, anoverall loss of acuity is more commonly observed. When the deficiency isgreat or of long standing, the vision loss (in whatever form) can bemore severe and more difficult to successfully treat. All of thesevariations in the nature, degree, and progression of vision loss inretinoid deficiency patients are well-known to clinicians.

Because the nature and degree of vision loss caused by the retinoiddeficiency disorder varies from patient to patient, the nature anddegree of meaningful improvement or recovery of vision will also varyfrom patient to patient. For example, regaining the ability to see inmoderate light can be a meaningful improvement that is manifested insome patients. For other patients a meaningful improvement will be toachieve restored peripheral vision, or a general improvement in acuity.Ideally, progressive loss of vision can be arrested and reversed by thisinvention. However, in cases where diagnosis and treatment occur early,treatment according to this invention may simply limit or slow theprogression of vision loss.

Clinically meaningful improvements can be documented by any of severalknown clinical measures discussed in this application, including acuity,field of vision, light sensitivity, the ability to perform life tasks ora combination of some or all of these. These measures and others are allwell known to the clinicians and are routinely used in clinicalpractice. Clinicians are easily able to identify and observe thesechanges as part of routine clinical evaluations of retinoid deficiencypatients. Consequently, clinicians are also easily able to observe theidentify improvements in vision that are meaningful in the context of agiven patient.

The term “subject” refers to a human patient. The term “patient” refersto a human having an endogenous retinal deficiency and/or a human whohas been diagnosed as having an endogenous retinal deficiency.

Visual Disorders Associated with Endogenous Retinoid Deficiency

The therapeutic regimens and methods of the invention are for thetreatment and amelioration of visual disorders associated with anendogenous retinoid deficiency in a subject, preferably loss of visualfunctions due to endogenous retinoid deficiencies. Such deficiencies arecharacterized by an absent, deficient or depleted level of one or moreendogenous retinoids, such as 11-cis-retinal. Thus, “endogenous retinoiddeficiency” refers to prolonged lower levels of endogenous retinoids ascompared to the levels found in a healthy eye of a subject of the samespecies. While a healthy eye of a subject may experience transientshortage of 11-cis-retinal, which leads to a brief period of blindnessfollowed by vision recovery, a subject with endogenous retinoiddeficiency is deficient in its ability to reliably or rapidly regeneratethe endogenous level of 11-cis-retinal, which leads to prolonged and/orpronounced 11-cis retinal deficits.

Endogenous retinoid deficiency can be caused by one or more defects inthe visual cycle which includes enzymatic deficiencies and impairedtransport processes between the photoreceptors and retinal pigmentepithelial cells (RPE). FIG. 1 schematically shows a vertebrate,preferably the human, visual cycle (or retinoid cycle), which operatesbetween the RPE and the outer segments of photoreceptors. 11-cis-retinalis regenerated through a series of enzymatic reactions and transportprocesses to and from the RPE after which it binds to opsin to formrhodopsin in the photoreceptor. Rhodopsin is then activated by light toform meta-rhodopsin which activates the phototransduction cascade whilethe bound cis-retinoid is isomerized to all-trans-retinal (von Lintig,J. et al., Trends Biochem Sci Feb. 24 (2010)).

Mutations in more than a dozen genes encoding retinal proteins have beenidentified that participate in several biochemical pathways in thevisual cycle. For example, mutations in genes that encodelecithin:retinoid acetyl transferase (the LRAT gene) and retinal pigmentepithelium protein 65 kDa (the RPE65 gene) disrupt the retinoid cycle,resulting in a deficiency of 11-cis-retinal, an excess of free opsin, anexcess of retinoid waste (e.g., degradation) products and/orintermediates in the recycling of all-trans-retinal, or the like.

Endogenous retinoid levels in a subject's eyes and deficiencies of suchlevels may be determined in accordance with the methods disclosed in,for example, U.S. Published Patent Application No. 2005/0159662 (thedisclosure of which is incorporated by reference herein in itsentirety). Other methods of determining endogenous retinoid levels in avertebrate eye and a deficiency of such retinoids include, for example,analysis by high pressure liquid chromatography (HPLC) of retinoids in ablood sample from a subject. For example, a blood sample can be obtainedfrom a subject and retinoid types and levels in the sample can beseparated and analyzed by normal phase high pressure liquidchromatography (HPLC) (e.g., with a HP 1100 HPLC and a Beckman,Ultrasphere-Si, 4.6 mm×250 mm column using 10% ethyl acetate/90% hexaneat a flow rate of 1.4 ml/minute). The retinoids can be detected by, forexample, detection at 325 nm using a diode-array detector and HPChemstation A.03.03 software. A deficiency in retinoids can bedetermined, for example, by comparison of the profile of retinoids inthe sample with a sample from a control subject (e.g., a normalsubject).

Various conditions can cause a subject to be predisposed to or developendogenous retinoid deficiency. For example, a subject that has an RPE65gene mutation or an LRAT gene mutation is genetically predisposed toendogenous retinoid deficiency and visual impairment that ultimatelylead to complete vision loss and severe retinal dystrophy. Inparticular, RPE65 and LRAT gene mutations are found in both LCA and arRPpatients. Even in the absence of any genetic defects in the visualcycle, an aging subject may nonetheless develop endogenous retinoiddeficiency.

Examples of visual disorders associated with endogenous retinoiddeficiency are discussed in detail below.

A. Leber Congenital Amaurosis (LCA)

One condition associated with endogenous retinoid deficiency is LeberCongenital Amaurosis (LCA). LCA is an inherited childhood disease withearly onset vision loss and retinal dystrophy. Mutations in the RPE65gene in patients with autosomal recessive retinitis pigmentosa (arRP) orLeber congenital amaurosis have been reported to cause 0.5% and 6% ofLCA cases, respectively (den Hollander, A. I. et al., Prog Ret Eye Res27:391-419, (2008) and den Hollander, A. I. et al., Proc Natl Acad SciUSA 95:3088-93 (1998)). These forms are characterized by a significantdeficiency of 11-cis-retinal, the visual chromophore that binds rod andcone opsins to form the visual pigments (rhodopsin and cone-pigments)(Redmond, T. M. et al., Nat Gen 20:344-51 (1998) and Batten, M. L. etal., J Biol Chem 279:10422-32 (2004)). Chronic deficiency of11-cis-retinal eventually results in photoreceptor degeneration (Travis,G. H. et al., Annu Rev Pharmacol Toxicol 47:469-512 (2007)). Theinterval between the loss of visual function and retinal degenerationcreates an opportunity for vision rescue.

In subjects having LCA due to an RPE65 gene mutation, retinyl estersbuild up in the retinal pigment epithelium (RPE) (Thompson, D. A. etal., Nat Gen 28:123-4 (2001) and Gu S. M. et al., Nat Gen 17:194-7(1997)), which eventually results in retinal degeneration.

Subjects having LCA due to an LRAT gene mutation are unable to makeesters and subsequently secrete any excess retinoids, which areassociated with early-onset severe retinal dystrophy and retinaldegeneration (Morimura H et al. Proc Natl Acad Sci USA 95:3088-93(1998)).

B. Retinitis Pigmentosa and Night Blindness (Nyctalopia)

Another condition associated with endogenous retinoid deficiency isnight blindness caused by, for example, retinitis pigmentosa (RP) orcongenital stationary night blindness (CSNB).

RP is a condition caused by defects in many different genes. To date, 19known and 17 uncharacterized gene mutations have been identified,causing great heterogeneity in the disease (Phelan, J. K. et al., MolVis. 6:116-124 (2000)). The age of onset for RP, as well as the severityof the disease, is a function of the mode of inheritance. RP may beinherited by autosomal dominant, autosomal recessive, or X-linkedtraits. Autsomal recessive RP (arRP) can occur in 20% of all RP cases.In recent years, mutations in the LRAT and RPE65 genes have beendiscovered in patients with arRP. These specific mutations are linked todefects in retinoid metabolism of the visual cycle and may result inphotoreceptor degeneration (Morimura, H. et al., Proc Natl Acad Sci USA.95(6):3088-3093 (1998)).

As noted herein, the protein encoded by the RPE65 gene has a biochemicalassociation with retinol binding protein and 11-cis-retinoldehydrogenase and is essential for 11-cis-retinal production(Gollapalli, D. R. et al., Biochemistry. 42(19):5809-5818 (2003) andRedmond, T. M. et al., Nat Genet. 20(4):344-351 (1998)). Preclinical andclinical information show that loss of the function of the RPE65 proteinblocks retinoid processing after esterification of vitamin A to membranelipids and results in loss of vision.

Early stages of typical RP are characterized by night blindness and lossof mid-peripheral visual field, reflecting primary rod impairment. Asthe disease progresses, patients lose far peripheral and central vision,eventually leading to blindness. Prominent clinical findings includebone spicule-shaped pigment in the retina and attenuated/abnormalelectroretinogram (ERG) responses. It is speculated that the absence ofRPE65 products would cause a massive, early degeneration ofphotoreceptors while substitution of amino acids would lead to a slowerpace of degeneration (Marlhens, F. et al., Eur J Hum Genet. 6(5):527-531(1998)).

CSNB and fundus albipunctatus are a group of diseases that aremanifested as night blindness, but there is not a progressive loss ofvision as in the RP. Some forms of CSNB are due to a delay in therecycling of 11-cis-retinal. Until recently, fundus albipunctatus wasthought to be a special case of CSNB where the retinal appearance isabnormal with hundreds of small white dots appearing in the retina. Ithas been recently been shown that fundus albipunctatus is also aprogressive disease, although much slower than RP. Fundus albipunctatusis caused by a gene defect that leads to a delay in the cycling of11-cis-retinal.

C. Age-Related Visual Disorders

Another condition associated with endogenous retinoid deficiency isage-related decrease in retinal photoreceptor function. As discussedherein, it has been recognized that inadequate availability and/orprocessing of vitamin A to the visual chromophore, 11-cis-retinal, canadversely affect vertebrate rhodopsin regeneration and visualtransduction (McBee, J. K. et al., Prog Retin Eye Res 20, 469-529(2001); Lamb, T. D. et al., Prog Retin Eye Res 23, 307-380 (2004); andTravis, G. H. et al., Annu Rev Pharmacol Toxicol (2006)). In aging,rhodopsin regeneration after light exposure is more delayed in humansand mice deprived of vitamin A due to either dietary deficiency orinadequate intestinal absorption (Lamb, T. D. et al., J. Prog Retin EyeRes 23, 307-380 (2004)). Moreover, treatment with vitamin A and itsderivatives may have beneficial effects in aging and retinal diseasessuch as Sorbsby's fundus dystrophy and retinitis pigmentosa (Jacobson,S. G., et al., Nat Genet 11, 27-32 (1995); and Berson, E. L., et al.,Arch Ophthalmol 111, 761-772 (1993)).

Age-related visual disorders include a slowing of rod-mediated darkadaptation after light exposure, a decrease in night vision(nyctalopia), and/or a decrease in contrast sensitivity. Age-relatedvisual disorders may also include wet or dry forms of age-relatedmacular degeneration (AMD).

AMD is one of the specific visual disorders associated with theposterior portion of the eyeball and is the leading cause of blindnessamong older people. AMD results in damage to the macula, a smallcircular area in the center of the retina. Because the macula is thearea which enables one to discern small details and to read or drive,its deterioration may bring about diminished visual acuity and evenblindness. People with AMD suffer deterioration of central vision butusually retain peripheral sight. In AMD, vision loss occurs whencomplications late in the disease either cause new blood vessels to growunder the retina or the retina atrophies.

D. Subject Populations

While any subject having a visual disorder associated with an endogenousretinoid deficiency (as defined herein) may be treated by thetherapeutic regimens and methods of the invention, there is aphysiological window of opportunity wherein the therapeutic regimen ormethod is the most effective in restoring visual function to thesubject. Preferably, the window of opportunity for the therapeuticregimens of the invention to be the most effective in a subject isdefined as the interval between loss of visual function and retinaldegeneration, particularly with respect to photoreceptor celldegeneration. Subjects in certain age groups may particularly benefitfrom the therapeutic regimens of the invention. More specifically,subjects with a lesser degree of retinal/photoreceptor degeneration tendto have a better or faster response to the therapeutic regimen of theinvention and/or may have a longer resting period before a subsequentdosing period is needed.

For example, in certain embodiments, younger subjects with a lost ofvisual function due to LCA or RP may retain a higher percentage ofdormant photoreceptors. Such dormant photoreceptors are capable ofresponding to the therapeutic regimens of the invention. In particular,in treating lost of visual function in a subject arising from inheritedchildhood blindness such as LCA or early onset RP, such as arRP, youngersubjects may expect a greater recovery of visual functions because theirretinal degeneration is less advanced. Thus, in one embodiment of theinvention, the subject is a human juvenile, i.e., younger than 15 years,old upon commencement of the therapeutic regimen. In other embodimentsof the invention, the subject is a human newborn or a human infantyounger than 1 year old, younger than 18 months, younger than 24 monthsor younger than 36 months old when the therapeutic regimen is commenced.In other embodiments, the subject is a human of 5 years old or olderwhen the therapeutic regimen is commenced. In further embodiments, thehuman subject is 10 years old or older when the therapeutic regimen iscommenced.

In some instances, RP may appear in a human subject during the seconddecade or even later. The average age of diagnosis for arRP in a humanis about 36 years old (Tsujikawa M. et al., Arch Ophthalmol 126(3)337-340 (2008)). Thus, in other embodiments, the human subject is 15years old or older when the therapeutic regimen is commenced. In morespecific embodiments, the human subject is 20 years old or older, 30years old or older, 40 years or older, 50 years or older, 60 years orolder or 70 years or older when the therapeutic regimen is commenced.

In further embodiments, the human subject is an aging subject sufferingfrom age-related retinal disorders. As used herein, an aging humansubject is typically at least 45, or at least 50, or at least 60, or atleast 65 years old when the therapeutic regimen is commenced.

Preferably, for any of these subjects, the therapeutic regimens andmethods of the invention should commence as soon as a diagnosis of avisual disorder as defined herein is ascertained, such that anydegeneration of the retina, in particular the photoreceptors, has notreached a point where the therapeutic regimens of the invention would beineffective in treating or ameliorating the visual disorder in thesubject.

Synthetic Retinal Derivatives of the Invention

The present invention provides methods of restoring or stabilizingphotoreceptor function in a subject's visual system. Synthetic retinalderivatives can be administered to restore or stabilize photoreceptorfunction, and/or to ameliorate the effects of a deficiency in retinoidlevels. Photoreceptor function can be restored or stabilized, forexample, by providing a synthetic retinoid that can act as an11-cis-retinoid replacement and/or an opsin agonist. The syntheticretinoid also can ameliorate the effects of a retinoid deficiency on asubject's visual system. A synthetic retinoid can be administeredprophylactically or therapeutically to a subject.

The synthetic retinal derivatives are retinoids derived from11-cis-retinal or 9-cis-retinal. In certain embodiments, the syntheticretinal derivative is a synthetic 9- or 11-cis retinoid. In otherembodiments, the synthetic retinoid is a derivative of 11-cis-retinal or9-cis-retinal, with the proviso that the synthetic retinoid is not9-cis-retinal. In some embodiments, a synthetic retinal derivative can,for example, be a retinoid replacement, supplementing the levels ofendogenous retinoid.

Without intending to be bound by any particular theory, the syntheticretinal derivatives used in the therapeutic regimens of the inventionprovide replacements for endogenously produced 11-cis-retinal, therebyrestoring the key biochemical component of the visual cycle. A syntheticretinal derivative suitable for the therapeutic regimens of theinvention can be a derivative of 9-cis-retinal or 11-cis-retinal. Like11-cis-retinal, 9-cis-retinal can bind to opsin to form photoactiveisorhodopsin which, when bleached, undergoes conformational changes viathe same photoproducts as 11-cis-retinal regenerated rhodopsin(Yoshizawa, T. et al., Nature 214, 566-571 (1967) and Filipek S. et al.,Annu Rev Physiol 65:851-79 (2003)). 9-cis-retinal and its derivativesare generally more thermodynamically stable than their 11-cis retinalcounterparts.

The synthetic retinal derivative can be converted directly or indirectlyinto a retinal or a synthetic retinal analog. Thus, in some aspects, thecompounds according to the present invention can be described aspro-drugs, which upon metabolic transformation are converted into9-cis-retinal, 11-cis-retinal or a synthetic retinal analog thereof.Metabolic transformation can occur, for example, by acid hydrolysis,esterase activity, acetyltransferase activity, dehydrogenase activity,or the like. For example, without wishing to be bound by theory, it isthought that a synthetic 9-cis-retinal derivative (e.g., 9-cis-retinylacetate), is converted to 9-cis-retinol in the alimentary pathway,transported to the retina through the bloodstream and converted to9-cis-retinal in the RPE.

Synthetic retinal derivatives suitable for the methods of the presentdisclosure can be those described in International Published PatentApplication Nos. WO 2004/082622 and WO 2006/002097, and Published U.S.Application Nos. 2004/0242704 and US 2010/0035986, which applicationsare incorporated herein by reference in their entireties.

The synthetic retinal derivative can bind to opsin and function as anopsin agonist. As used herein, the term “agonist” refers to a syntheticretinal derivative that binds to opsin and facilitates the ability ofthe opsin/synthetic retinal derivative complex to respond to light. Asan opsin agonist, a synthetic retinal derivative can create apharmacological bypass of a blocked retinoid cycle, thus sparing therequirement for endogenous retinoid (e.g., 11-cis-retinal).

Synthetic retinal derivative include 11-cis-retinal derivatives or9-cis-retinal derivatives such as, for example, the following: acyclicretinals; retinals with modified polyene chain length, such as trienoicor tetraenoic retinals; retinals with substituted polyene chains, suchas alkyl, halogen or heteratom-substituted polyene chains; retinals withmodified polyene chains, such as trans- or cis-locked polyene chains, orwith, for example, allene, alkane, alkene or alkyne modifications; andretinals with ring modifications, such as heterocyclic, heteroaromaticor substituted cycloalkane or cycloalkene rings.

In certain embodiments, the synthetic retinal derivative can be aretinal of the following formula I:

R and R1 can be independently selected from linear, iso-, sec-, tert-and other branched alkyl groups as well as substituted alkyl groups,substituted branched alkyl, hydroxyl, hydroalkyl, amine, amide, or thelike. R and R1 can independently be lower alkyl, which means straight orbranched alkyl with 1-6 carbon atom(s) such as methyl, ethyl, propyl,isopropyl, butyl, isobutyl, tert-butyl, pentyl, hexyl, or the like.Suitable substituted alkyls and substituted branch alkyls include, forexample, alkyls, branched alkyls and cyclo-alkyls substituted withoxygen, hydroxyl, nitrogen, amide, amine, halogen, heteroatom or othergroups. Suitable heteroatoms include, for example, sulfur, silicon, andfluoro- or bromo-substitutions.

In certain additional embodiments, R or R1 can be a cyclo-alkyl such as,for example, hexane, cyclohexene, benzene as well as substitutedcyclo-alkyl. Suitable substituted cyclo alkyl include, for example,cyclo-alkyls substituted with oxygen, hydroxyl, nitrogen, amide, amine,halogen, heteroatom or other groups. Suitable heteroatoms include, forexample, sulfur, silicon, and fluoro- or bromo-substitutions.

The synthetic retinal derivative also can be a derivative of an11-cis-retinal or 9-cis-retinal that has a modified polyene chain lengthof the following formula II:

The polyene chain length can be extended by 1, 2, or 3 alkyl, alkene oralkylene groups. According to formula II, each n and n1 can beindependently selected from 1, 2, or 3 alkyl, alkene or alkylene groups,with the proviso that the sum of the n and n1 is at least 1.

The synthetic retinal derivative also can be a derivative of an11-cis-retinal or 9-cis-retinal that has a substituted polyene chain ofthe following formula III:

Each of R₁ to R₉ can be independently selected from hydrogen, alkyl,branched alkyl, cyclo-alkyl, halogen, a heteratom, or the like. Suitablealkyls include, for example, methyl, ethyl, propyl, substituted alkyl(e.g., alkane with hydroxyl, hydroalkyl, amine, amide) or the like.Suitable branched alkyl can be, for example, isopropyl, isobutyl,substituted branched alkyl, or the like. Suitable cyclo-alkyls caninclude, for example, cyclohexane, cycloheptane, and other cyclicalkanes as well as substituted cyclic alkanes such as substitutedcyclohexane or substituted cycloheptane. Suitable halogens include, forexample, bromine, chlorine, fluorine, or the like. Suitable heteroatomsinclude, for example, sulfur, silicon, and fluoro- orbromo-substitutions. Suitable substituted alkyls, substituted branchalkyls and substituted cyclo-alkyls include, for example, alkyls,branched alkyls and cyclo-alkyls substituted with oxygen, hydroxyl,nitrogen, amide, amine, halogen, a heteroatom or other groups. Inexemplary embodiments, the synthetic retinoid is 9-ethyl-11-cis-retinal,7-methyl-11-cis-retinal, 13-desmethyl-11-cis-retinal,11-cis-10-F-retinal, 11-cis-10-Cl-retinal, 11-cis-10-methyl-retinal,11-cis-10-ethyl-retinal, 9-cis-10-F-retinal, 9-cis-10-Cl-retinal,9-cis-10-methyl-retinal, 9-cis-10-ethyl-retinal, 11-cis-12-F-retinal,11-cis-12-Cl-retinal, 11-cis-12-methyl-retinal, 11-cis-10-ethyl-retinal,9-cis-12-F-retinal, 9-cis-12-Cl-retinal, 9-cis-12-methyl-retinal,11-cis-14-F-retinal, 11-cis-14-methyl-retinal, 11-cis-14-ethyl-retinal,9-cis-14-F-retinal, 9-cis-14-methyl-retinal, 9-cis-14-ethyl-retinal, orthe like.

The synthetic retinal derivaitve further can be derivative of an11-cis-retinal or 9-cis-retinal that has a modified ring structure.Suitable examples include, for example, derivatives containing ringmodifications, aromatic analogs and heteroaromatic analogs of thefollowing formulae IV, V and VI, respectively:

Each of R1 to R5 or R6, as applicable, can be independently selectedfrom hydrogen, alkyl, substituted alkyl, hydroxyl, hydroalkyl, amine,amide, halogen, a heteratom, or the like. Suitable alkyls include, forexample, methyl, ethyl, propyl, isopropyl, butyl, isobutyl or the like.Suitable halogens include, for example, bromine, chlorine, fluorine, orthe like. Suitable heteroatoms include, for example, sulfur, silicon, ornitrogen. In addition, X can be a heteroatoms, such as, for example,sulfur, silicon, or nitrogen.

The synthetic retinal derivative can further be a derivative of an11-cis-retinal or 9-cis-retinal that has a modified polyene chain.Suitable derivatives include, for example, those with a trans/cis lockedconfiguration, 6s-locked analogs, as well as modified allene, alkene,alkyne or alkylene groups in the polyene chain. In one example, thederivative is an 11-cis-locked analog of the following formula VII:

R can be, for example, hydrogen, methyl or other lower alkane orbranched alkane. n can be 0 to 4. m plus 1 equals 1, 2 or 3.

In a specific embodiment, the synthetic retinal derivative is a11-cis-locked analog of the following formula VIII:

n can be 1 to 4.

In certain exemplary embodiments, the synthetic retinoid is9,11,13-tri-cis-7-ring retinal, 11,13-di-cis-7-ring retinal,11-cis-7-ring retinal or 9,11-di-cis-7-ring retinal.

In another example, the synthetic retinal derivative is a 6s-lockedanalog of formula IX. R1 and R2 can be independently selected fromhydrogen, methyl and other lower alkyl and substituted lower alkyl. R3can be independently selected from an alkene group at either of theindicated positions.

In other embodiments, the synthetic retinoid can be a 9-cis-ring-fusedderivative, such as, for example, those shown in formulae X-XII.

In yet another embodiment, the synthetic retinoid is of the followingformula XIII.

Each of R₁ to R₁₅ can be independently selected from hydrogen, alkyl,branched alkyl, halogen, hydroxyl, hydroalkyl, amine, amide, aheteratom, or the like. Suitable alkyls include, for example, methyl,ethyl, propyl, substituted alkyl (e.g., alkyl with hydroxyl, hydroalkyl,amine, amide), or the like. Suitable branched alkyl can be, for example,isopropyl, isobutyl, substituted branched alkyl, or the like. Suitablehalogens include, for example, bromine, chlorine, fluorine, or the like.Suitable heteroatoms include, for example, sulfur, silicon, and fluoro-or bromo-substitutions. Suitable substituted alkyls and substitutedbranch alkyls include, for example, alkyls and branched alkylssubstituted with oxygen, hydroxyl, nitrogen, amide, amine, halogen,heteroatom or other groups. Each of n and n₁ can be independentlyselected from 1, 2, or 3 alkyl, alkene or alkylene groups, with theproviso that the sum of the n and n₁ is at least 1. In addition, R₁₁-R₁₂and/or R₁₃-R₁₄ can comprise an alkene group in the cyclic carbon ring.In certain embodiments, R₅ and R₇ together can form a cyclo-alkyl, suchas a five, six, seven or eight member cyclo-alkyl or substitutedcyclo-alkyl, such as, for example, those shown in formulae VII, VIII, X,XI and XII.

In additional embodiments, the synthetic retinal derivative also can be9-cis-retinal. Alternatively, 11-cis-retinal can be used.

In additional embodiments, the synthetic retinal derivatives arederivatives of 9-cis-retinal or 11-cis-retinal in which the aldehydicgroup in the polyene chain is converted to an ester, ether, alcohol,hemi-acetal, acetal or oxime. Such synthetic retinal derivatives include9-cis-retinyl esters, 9-cis-retinyl ethers, 9-cis-retinol, 9-cis-retinaloximes, 9-cis-retinyl acetals, 9-cis-retinyl hemiacetals, 11-cis-retinylesters, 11-cis-retinyl ethers, 11-cis-retinol, 11-cis-retinyl oximes,11-cis-retinyl acetals and 11-cis-retinyl hemiacetals, as furtherdescribed herein.

In one aspect, the synthetic retinal derivative is a retinyl ester. Insome embodiments, the retinyl ester is a 9-cis-retinyl ester or an11-cis-retinyl ester. The ester substituent can be, for example, acarboxylic acid, such as a mono- or polycarboxylic acid. As used herein,a “polycarboxylic acid” is a di-, tri- or higher order carboxylic acid.In some embodiments, the carboxylic acid is a C1-C22, C2-C22, C3-C22,C1-C10, C2-C10, C3-C10, C4-C10, C4-C8, C4-C6 or C4 monocarboxylic acid,or polycarboxylic acid.

Suitable carboxylic acid groups include, for example, acetic acid,propionic acid, butyric acid, valeric acid, caproic acid, caprylic acid,pelargonic acid, capric acid, lauric acid, oleic acid, stearic acid,palmitic acid, myristic acid or linoleic acid. The carboxylic acid alsocan be, for example, oxalic acid (ethanedioic acid), malonic acid(propanedioic acid), succinic acid (butanedioic), fumaric acid(butenedioic acid), malic acid (2-hydroxybutenedioic acid), glutaricacid (pentanedioic acid), adipic acid (hexanedioic acid), pimelic acid(heptanedioic), suberic acid (octanedioic), azelaic acid (nonanedioicacid), sebacic acid (decanedioic acid), citric acid, oxaloacetic acid,ketoglutaratic acid, or the like.

In an exemplary embodiment, the retinyl ester is a 9-cis-retinyl esteror an 11-cis-retinyl ester including a C3-C10 polycarboxylic acidsubstituent. (In this context, the terms “substituent” or “group” referto a radical covalently linked to the terminal oxygen in the polyenechain.). In another exemplary embodiment, the retinyl ester is a9-cis-retinyl ester or an 11-cis-retinyl ester including a C2-C22 orC3-C22 polycarboxylic acid substituent. The polycarboxylic acidsubstituent can be, for example, succinate, citrate, ketoglutarate,fumarate, malate or oxaloacetate. In another exemplary embodiment, theretinyl ester is a 9-cis-retinyl ester or an 11-cis-retinyl esterincluding a C3-C22 di-carboxylic acid (di-acid) substituent. In someembodiments, the polycarboxylic acid is not 9-cis-retinyl tartarate or11-cis-retinyl tartarate. In some embodiments, the retinyl ester is nota naturally occurring retinyl ester normally found in the eye. In someembodiments, the retinyl ester is an isolated retinyl ester. As usedherein, “isolated” refers to a molecule that exists apart from itsnative environment and is therefore not a product of nature. An isolatedmolecule may exist in a purified form or may exist in a non-nativeenvironment.

In one aspect, the retinal derivative can be a 9-cis-retinyl ester orether of the following formula XIV:

In some embodiments, A is CH2OR, where R can be an aldehyde group, toform a retinyl ester. A suitable aldehyde group is a C1 to C24 straightchain or branched aldehyde group. In additional embodiments, thealdehyde groups is a C1 to C14 straight chain or branched aldehydegroup. In other embodiments, the aldehyde group is a C1 to C12 straightchain or branched aldehyde group, such as, for example, acetaldehyde,propionaldehyde, butyraldehyde, valeraldehyde, hexanal, heptanal,octanal, nonanal, decanal, undecanal, dodecanal. In other embodiments, Rcan be a C1 to C10 straight chain or branched aldehyde group, a C1 to C8straight chain or branched aldehyde group or a C1 to C6 straight chainor branched aldehyde group. (As used herein, the term “group” refers toa radical covalently linked to the oxygen.) In some embodiments, theretinyl ester is not a naturally occurring retinal ester normally foundin the eye.

In additional embodiments, R can be an aldehyde group of a dicarboxylicacid or other carboxylic acid (e.g., a hydroxyl acid) to form a retinylester (some of which are also referred to as retinoyl esters), such asoxalic acid (ethanedioic acid), malonic acid (propanedioic acid),succinic acid (butadedioic), fumaric acid (butenedioic acid), malic acid(2-hydroxybutenedioic acid), glutaric acid (pentanedioic acid), adipicacid (hexanedioic acid), pimelic acid (heptanedioic), suberic acid(octanedioic), azelaic acid (nonanedioic acid), sebacic acid(decanedioic acid), citric acid, oxaloacetic acid, ketoglutaratic acid,or the like.

R can also be an alkane group, to form a retinyl alkane ether. Suitablealkane groups include, for example, C1 to C24 straight chain or branchedalkyls, such as, for example, methane, ethane, butane, isobutane,pentane, isopentane, hexane, heptane, octane or the like. In someembodiments, the alkane group can be a linear, iso-, sec-, tert- orother branched lower alkyl ranging from C1 to C6. In other embodiments,the alkane group can be a linear, iso-, sec-, tert- or other branchedmedium chain length alkyl ranging from C8 to C14. In additionalembodiments, the alkane group can be a linear, iso-, sec-, tert- orother branched long chain length alkyl ranging from C16 to C24.

R further can be an alcohol group, to form a retinyl alcohol ether.Suitable alcohol groups can be linear, iso-, sec-, tert- or otherbranched lower alcohols ranging from C1 to C6, linear, iso-, sec-, tert-or other branched medium chain length alcohols ranging from C8 to C14,or linear, iso-, sec-, tert- or other branched long chain length alkylranging from C16 to C24. In some embodiments, the alcohol group can be,for example, methanol, ethanol, butanol, isobutanol, pentanol, hexanol,heptanol, octanol, or the like.

R can also be a carboxylic acid, to form a retinyl carboxylic acidether. Suitable alcohol groups can be linear, iso-, sec-, tert- or otherbranched lower carboxylic acids ranging from C1 to C6, linear, iso-,sec-, tert- or other branched medium chain length carboxylic acidsranging from C8 to C14, or linear, iso-, sec-, tert- or other branchedlong chain length carboxylic acids ranging from C16 to C24. Suitablecarboxylic acid groups include, for example, acetic acid, propionicacid, butyric acid, valeric acid, caproic acid, caprylic acid,pelargonic acid, capric acid, lauric acid, oleic acid, stearic acid,palmitic acid, myristic acid, linoleic acid, succinic acid, fumaric acidor the like.

In another embodiments, the retinyl derivative is a retinyl hemiacetal,where A is CH(OH)OR. R can be any of the R groups set forth above inFormula XIV. R is typically a lower alkane, such as a methyl or ethylgroup, or a C1 to C7 saturated and unsaturated, cyclic or acyclicalkane, with or without hetero atoms, as described herein.

In yet other embodiments, the retinyl derivative is a retinyl acetal,where A is CH (ORa)ORb. Each of Ra and Rb can be independently selectedfrom any of the R groups set forth above in Formula XIV. Ra and Rb aretypically a C1 to C7 saturated and unsaturated, cyclic or acyclicalkane, with or without hetero atoms, as described herein.

In yet a further embodiments, the retinyl derivative is a retinyl oxime,where A is CH:NOH, or CH:NOR. R can be any of the R groups set forthabove in Formula XIV. R is typically a hydrogen, or an alkane.

Examples of suitable synthetic retinal derivatives include, for example,9-cis-retinyl acetate, 9-cis-retinyl formate, 9-cis-retinyl succinate,9-cis-retinyl citrate, 9-cis-retinyl ketoglutarate, 9-cis-retinylfumarate, 9-cis-retinyl malate, 9-cis-retinyl oxaloacetate,9-cis-retinal oxime, 9-cis-retinal O-methyl oximes, 9-cis-retinalO-ethyl oximes, and 9-cis-retinal methyl acetals and hemi acetals,9-cis-retinyl methyl ether, 9-cis-retinyl ethyl ether, and 9-cis-retinylphenyl ether

In a related aspect, the retinal derivative can be an 11-cis-retinylester or ether of the following formula XV:

A can be any of the groups set forth above in Formula XIV.

Examples of suitable synthetic retinal derivatives include, for example,11-cis-retinyl acetate, 11-cis-retinyl formate, 11-cis-retinylsuccinate, 11-cis-retinyl, 11-cis-retinyl citrate, 11-cis-retinylketoglutarate, 11-cis-retinyl fumarate, 11-cis-retinyl malate,11-cis-retinal oxime,11-cis-retinal O-methyl oxime, 11-cis-retinalO-ethyl oximes and 11-cis-retinal methyl acetals and hemi acetals,11-cis-retinyl methyl ether, 11-cis-retinyl ethyl ether.

In additional aspects, the synthetic retinal derivatives can be, forexample, a derivative of a 9-cis-retinyl ester, a 9-cis-retinyl ether,an 11-cis-retinyl ester or an 11-cis-retinyl ethers such as, forexample, an acyclic retinyl ester or ethers, a retinyl ester or etherwith a modified polyene chain length, such as a trienoic or tetraenoicretinyl ester or ether; a retinyl ester or ether with a substitutedpolyene chain, such as alkyl, halogen or heteratom-substituted polyenechains; a retinyl ester or ether with a modified polyene chain, such asa trans- or cis-locked polyene chain, or with, for example, allene oralkyne modifications; and a retinyl ester or ether with a ringmodification(s), such as heterocyclic, heteroaromatic or substitutedcycloalkane or cycloalkene rings.

In other embodiments, the synthetic retinal derivative can be a retinylester or ether of the following formula XVI:

A can be any of the groups set forth above for formula (XIV). R1 and R2can be independently selected from linear, iso-, sec-, tert- and otherbranched alkyl groups as well as substituted alkyl groups, substitutedbranched alkyl, hydroxyl, hydroalkyl, amine, amide, or the like. R1 andR2 can independently be lower alkyl, which means straight or branchedalkyl with 1-6 carbon atom(s) such as methyl, ethyl, propyl, isopropyl,butyl, isobutyl, tert-butyl, pentyl, hexyl, or the like. Suitablesubstituted alkyls and substituted branch alkyls include, for example,alkyls, branched alkyls and cyclo-alkyls substituted with oxygen,hydroxyl, nitrogen, amide, amine, halogen, heteroatom or other groups.Suitable heteroatoms include, for example, sulfur, silicon, and fluoro-or bromo-substitutions.

In certain additional embodiments, R1 or R2 can be a cyclo-alkyl suchas, for example, hexane, cyclohexene, benzene as well as a substitutedcyclo-alkyl. Suitable substituted cyclo-alkyls include, for example,cyclo-alkyls substituted with oxygen, hydroxyl, nitrogen, amide, amine,halogen, heteroatom and/or other groups. Suitable heteroatoms include,for example, sulfur, silicon, and fluoro- or bromo-substitutions.

The synthetic retinal derivative also can have a modified polyene chainlength, such as the following formula XVII:

A can be any of the groups set forth above for formula (XIV). Thepolyene chain length can be extended by 1, 2, or 3 alkyl, alkene oralkylene groups. According to formula (XVI), each n and n1 can beindependently selected from 1, 2, or 3 alkyl, alkene or alkylene groups,with the proviso that the sum of the n and n1 is at least 1.

The synthetic retinal derivative also can have a substituted polyenechain of the following formula XVIII:

A can be any of the groups set forth above for formula (XIV). Each of R1to R8 can be independently selected from hydrogen, alkyl, branchedalkyl, cyclo-alkyl, halogen, a heteratom, or the like. Suitable alkylsinclude, for example, methyl, ethyl, propyl, substituted alkyl (e.g.,alkyl with hydroxyl, hydroalkyl, amine, amide) or the like. Suitablebranched alkyls can be, for example, isopropyl, isobutyl, substitutedbranched alkyl, or the like. Suitable cyclo-alkyls can include, forexample, cyclohexane, cycloheptane, and other cyclic alkanes as well assubstituted cyclic alkanes such as substituted cyclohexane orsubstituted cycloheptane. Suitable halogens include, for example,bromine, chlorine, fluorine, or the like. Suitable heteroatoms include,for example, sulfur, silicon, and fluoro- or bromo-substitutions.Suitable substituted alkyls, substituted branch alkyls and substitutedcyclo-alkyls include, for example, alkyls, branched alkyls andcyclo-alkyls substituted with oxygen, hydroxyl, nitrogen, amide, amine,halogen, heteroatom or other groups. In exemplary embodiments, thesynthetic retinal derivative is selected from the following: a9-ethyl-11-cis-retinyl ester, ether, oxime, acetal or hemiacetal; a7-methyl-11-cis-retinyl ester, ether, oxime, acetal or hemiacetal; a13-desmethyl-11-cis-retinyl ester, ether, oxime, acetal or hemiacetal;an 11-cis-10-F-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-10-Cl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-10-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-10-ethyl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-10-F-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-10-Cl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-10-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-10-ethyl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-12-F-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-12-Cl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-12-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-10-ethyl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-12-F-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-12-Cl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-12-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-14-F-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-14-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; an11-cis-14-ethyl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-14-F-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-14-methyl-retinyl ester, ether, oxime, acetal or hemiacetal; a9-cis-14-ethyl-retinyl ester, ether, oxime, acetal or hemiacetal; or thelike.

The synthetic retinal derivative further can have a modified ringstructure. Suitable examples include, for example, derivativescontaining ring modifications, aromatic analogs and heteroaromaticanalogs of the following formulae XIX, XX and XXI, respectively:

A can be any of the groups set forth above for formula (XIV). Each of R1to R6, as applicable, can be independently selected from hydrogen,alkyl, substituted alkyl, hydroxyl, hydroalkyl, amine, amide, halogen, aheteratom, or the like. Suitable alkyls include, for example, methyl,ethyl, propyl, isopropyl, butyl, isobutyl or the like. Suitable halogensinclude, for example, bromine, chlorine, fluorine, or the like. Suitableheteroatoms include, for example, sulfur, silicon, or nitrogen. Informulae VII, X can be, for example, sulfur, silicon, nitrogen, fluoro-or bromo-substitutions.

The synthetic retinal derivative also can have a modified polyene chain.Suitable derivatives include, for example, those with a trans/cis lockedconfiguration, 6s-locked analogs, as well as modified allene, alkene,alkyne or alkylene groups in the polyene chain. In one example, thederivative is an 11-cis-locked analog of the following formula XXII:

A can be any of the groups set forth above for formula (XIV). R3 can be,for example, hydrogen, methyl or other lower alkane or branch alkane. ncan be 0 to 4; m plus 1 equals 1, 2 or 3.

In a specific embodiment, the synthetic retinal derivative is an11-cis-locked analog of the following formula XXIII:

n can be 1 to 4. A can be any of the groups set forth above for formula(XIV).

In certain exemplary embodiments, the synthetic retinal derivative is a9,11,13-tri-cis-7-ring retinyl ester or ether, an 11,13-di-cis-7-ringretinyl ester or ether, an 11-cis-7-ring retinyl ester or ether or a9,11-di-cis-7-ring retinyl ester or ether.

In another example, the synthetic retinal derivative is a 6s-lockedanalog of formula XXIV. A can be any of the groups set forth above forformula (XIV). R₁ and R₂ can be independently selected from hydrogen,methyl and other lower

alkyl and substituted lower alkyl. R₃ can be independently selected froman alkene group at either of the indicated positions.

In other embodiments, the synthetic retinal derivative can be a9-cis-ring-fused derivative, such as, for example, those shown informulae XXV-XXVII. A can be any of the groups set forth above forformula (XIV).

In yet another embodiment, the synthetic retinal derivative is of thefollowing formula XXVIII or XXIXI.

A can be any of the groups set forth above for formula (XIV). Each of R2to R5, R7 to R14, R16 and R17 can be absent or independently selectedfrom hydrogen, alkyl, branched alkyl, halogen, hydroxyl, hydroalkyl,amine, amide, a heteratom, or the like. Suitable alkyls include, forexample, methyl, ethyl, propyl, substituted alkyl (e.g., alkyl withhydroxyl, hydroalkyl, amine, amide), or the like. Suitable branchedalkyl can be, for example, isopropyl, isobutyl, substituted branchedalkyl, or the like. Suitable halogens include, for example, bromine,chlorine, fluorine, or the like. Suitable heteroatoms include, forexample, sulfur, silicon, and fluoro- or bromo-substitutions. Suitablesubstituted alkyls and substituted branch alkyls include, for example,alkyls and branched alkyls substituted with oxygen, hydroxyl, nitrogen,amide, amine, halogen, heteroatom or other groups. Each of n and n1 canbe independently selected from 1, 2, or 3 alkyl, alkene or alkylenegroups, with the proviso that the sum of the n and n1 is at least 1. Inaddition, R3-R4 and/or R2-R1 can comprise an alkene group in the cycliccarbon ring, in which case. In certain embodiments, R10 and R13 togethercan form a cyclo-alkyl, such as a five, six, seven or eight membercyclo-alkyl or substituted cyclo-alkyl, such as, for example, thoseshown in Formulae XXII, XXIII, XXVI, XXVI and XXVII.

In another embodiment of the invention, synthetic retinal derivativesare 9-cis-retinyl esters of the following formula (XXX):

wherein R is an alkyl group or an alkenyl group.

In this embodiment, “alkyl” refers to a straight or branched hydrocarbonchain radical consisting solely of carbon and hydrogen atoms, containingno unsaturation, having up to twenty two carbon atoms. In certainembodiments, an alkyl may comprise twelve to seventeen carbon atoms(also referred to as “C12-17 alkyl”). In certain embodiments, an alkylmay comprise twelve to fifteen carbon atoms (also referred to as “C12-15alkyl”). In certain embodiments, an alkyl may comprise one to eightcarbon atoms (also referred to as “C1-8 alkyl”). In other embodiments,an alkyl may comprise one to six carbon atoms (also referred to as “C1-6alkyl”). In further embodiments, an alkyl may comprise one to fourcarbon atoms (also referred to as “C1-4 alkyl”). The alkyl is attachedto the rest of the molecule by a single bond, for example, methyl,ethyl, n-propyl, 1-methylethyl (iso-propyl), n-butyl, n-pentyl,1,1-dimethylethyl (t-butyl), 3-methylhexyl, 2-methylhexyl, and the like.Unless stated otherwise specifically in the specification, an alkylgroup may be optionally substituted by one or more of the followingsubstituents: halo (including —F, —Br, —Cl and —I), cyano (—CN), nitro(—NO2), oxo (═O), and hydroxyl (—OH).

“Alkenyl” refers to a straight or branched hydrocarbon chain radicalconsisting solely of carbon and hydrogen atoms, containing at least oneunsaturation (i.e., C═C), having from two to up to twenty carbon atoms.In various embodiments, R is C12-17 alkenyl, C1-8 alkenyl, C1-6 alkenylor C1-4 alkenyl. Unless stated otherwise specifically in thespecification, an alkyl group may be optionally substituted by one ormore of the following substituents: halo (including —F, —Br, —Cl and—I), cyano (—CN), nitro (—NO2), oxo (═O), and hydroxyl (—OH).

In certain embodiments, the 9-cis-retinyl esters are artificialretinoids that act as precursors (i.e., pre-drugs) of a pro-drug form of9-cis-retinal. More specifically, the 9-cis-retinyl esters can beconverted by the liver to a metabolic pro-drug form, namely fatty acid9-cis-retinyl esters, which are stored in the liver in hepatic lipiddroplets. Fatty acid 9-cis-retinyl esters and retinol are mobilized fromthe liver and enter the circulation where they travel to the eye andRPE. There, they are converted to 9-cis-retinal which ultimatelycombines with photoreceptor opsins to form active visual pigments.

A preferred 9-cis-retinyl ester is 9-cis-retinyl acetate (i.e., R ismethyl). Also referred to as “9-cis-R-Ac”, 9-cis-retinyl acetate is apharmaceutical pre-drug, which is metabolized by the liver to fatty acid9-cis-retinyl esters, such as 9-cis-retinyl palmitate. Fatty acid9-cis-retinyl esters and retinol are then converted to 9-cis-retinal inthe eye and RPE as replacement of deficient chromophores such as11-cis-retinal.

9-cis-R-Ac can be prepared by initially converting all-trans-retinylacetate (Sigma-Aldrich) to a mixture of 9-cis-retinyl acetate andall-trans-retinyl acetate in the presence of a palladium catalyst (e.g.,palladium salts, palladium oxides). The mixture of 9-cis-retinyl acetateand all-trans-retinyl acetate are then hydrolyzed to produce a mixtureof 9-cis-retinol and all-trans-retinol. The pure 9-cis-retinol can beisolated by selective recrystallization and further esterified to pure9-cis-R-Ac. A detailed description of the processes for preparing andpurifying 9-cis-R-Ac can be found, for example, in GB Patent No.1452012.

In other embodiments, the retinyl esters are pro-drugs (rather thanprecursors of pro-drugs) and can be directly converted to 9-cis-retinalin the eye and RPE. The pro-drug forms of the 9-cis-retinyl esters aretypically fatty acid 9-cis-retinyl esters, in which R is a C11-21 alkyl.As used herein, “fatty acid” refers to a carboxylic acid having a longaliphatic chain, which can be saturated (alkyl) or unsaturated(alkenyl). Typically, the aliphatic chain contains at least 11 carbonsand can be as long as 21 carbons. Exemplary fatty acids include, withoutlimitation, lauric acid, palmitic acid, palmitoleic acid, oleic acid,linoleic acid, and linolenic acid.

Thus, in one embodiment, R is a C15 alkyl, and the 9-cis-retinyl esterof Formula (XXX) is 9-cis-retinyl palmitate.

In a further embodiment, R is a C17 alkyl, and the 9-cis-retinyl esterof Formula (XXX) is 9-cis-retinyl stearate.

In other embodiment, R is a C17 alkenyl, and the 9-cis-retinyl ester ofFormula (XXX) is 9-cis-retinyl oleate.

The 9-cis-retinyl esters described herein can be prepared from9-cis-retinol using appropriate esterifying agents in a manner similarto the preparation of 9-cis-R—Ac, the methods of which are within theknowledge of one skilled in the art.

Methods of making synthetic retinals and derivatives are disclosed in,for example, the following references: Anal. Biochem. 272:232-42 (1999);Angew. Chem. 36:2089-93 (1997); Biochemistry 14:3933-41 (1975);Biochemistry 21:384-93 (1982); Biochemistry 28:2732-39 (1989);Biochemistry 33:408-16 (1994); Biochemistry 35:6257-62 (1996);Bioorganic Chemistry 27:372-82 (1999); Biophys. Chem. 56:31-39 (1995);Biophys. J. 56:1259-65 (1989); Biophys. J. 83:3460-69 (2002); Chemistry7:4198-204 (2001); Chemistry (Europe) 5:1172-75 (1999); FEBS 158:1(1983); J. American Chem. Soc. 104:3214-16 (1982); J. Am. Chem. Soc.108:6077-78 (1986); J. Am. Chem. Soc. 109:6163 (1987); J. Am. Chem. Soc.112:7779-82 (1990); J. Am. Chem. Soc. 119:5758-59 (1997); J. Am. Chem.Soc. 121:5803-04 (1999); J. American Chem. Soc. 123:10024-29 (2001); J.American Chem. Soc. 124:7294-302 (2002); J. Biol. Chem. 276:26148-53(2001); J. Biol. Chem. 277:42315-24 (2004); J. Chem. Soc.—Perkin T.1:1773-77 (1997); J. Chem. Soc.—Perkin T. 1:2430-39 (2001); J. Org.Chem. 49:649-52 (1984); J. Org. Chem. 58:3533-37 (1993); J. PhysicalChemistry B 102:2787-806 (1998); Lipids 8:558-65; Photochem. Photobiol.13:259-83 (1986); Photochem. Photobiol. 44:803-07 (1986); Photochem.Photobiol. 54:969-76 (1991); Photochem. Photobiol. 60:64-68 (1994);Photochem. Photobiol. 65:1047-55 (1991); Photochem. Photobiol. 70:111-15(2002); Photochem. Photobiol. 76:606-615 (2002); Proc. Natl Acad. Sci.USA 88:9412-16 (1991); Proc. Natl Acad. Sci. USA 90:4072-76 (1993);Proc. Natl Acad. Sci. USA 94:13442-47 (1997); and Proc. R. Soc. Lond.Series B, Biol. Sci. 233(1270): 55-76 1988) (the disclosures of whichare incorporated by reference herein).

Retinyl esters can be formed by methods known in the art such as, forexample, by acid-catalyzed esterification of a retinol with a carboxylicacid, by reaction of an acyl halide with a retinol, bytransesterification of a retinyl ester with a carboxylic acid, byreaction of a primary halide with a carboxylate salt of a retinoic acid,or the like. In an exemplary embodiment, retinyl esters can be formed byacid-catalyzed esterification of a retinol with a carboxylic acid, suchas, acetic acid, propionic acid, butyric acid, valeric acid, caproicacid, caprylic acid, pelargonic acid, capric acid, lauric acid, oleicacid, stearatic acid, palmitic acid, myristic acid, linoleic acid,succinic acid, fumaric acid or the like. In another exemplaryembodiment, retinyl esters can be formed by reaction of an acyl halidewith a retinol (see, e.g., Van Hooser et al., Proc. Natl. Acad. Sci.USA, 97:8623-28 (2000)). Suitable acyl halides include, for example,acetyl chloride, palmitoyl chloride, or the like.

Retinyl ethers can be formed by methods known in the art, such as forexample, reaction of a retinol with a primary alkyl halide.

In certain embodiments, trans-retinoids can be isomerized tocis-retinoids by exposure to UV light. For example, all-trans-retinal,all-trans-retinol, all-trans-retinyl ester or all-trans-retinoic acidcan be isomerized to 9-cis-retinal, 9-cis-retinol, 9-cis-retinyl esteror 9-cis-retinoic acid, respectively. trans-Retinoids can be isomerizedto 9-cis-retinoids by, for example, exposure to a UV light having awavelength of about 365 nm, and substantially free of shorterwavelengths that cause degradation of cis-retinoids, as furtherdescribed herein.

Retinyl acetals and hemiacetals can be prepared, for example, bytreatment of 9-cis- and 11-cis-retinals with alcohols in the presence ofacid catalysts. Water formed during reaction is removed, for example byAl2O3 of a molecular sieve.

Retinyl oximes can be prepared, for example, by reaction of a retinalwith hydroxylamine, O-methyl- or O-ethylhydroxyl amine, or the like.

Retinyl esters can be formed by methods known in the art such as, forexample, by acid-catalyzed esterification of a retinol with a carboxylicacid, by reaction of an acyl halide with a retinol, bytransesterification of a retinyl ester with a carboxylic acid, byreaction of a primary halide with a carboxylate salt of a retinoic acid,by acid-catalyzed reaction of an anhydride with a retinol, or the like.In an example, retinyl esters can be formed by acid-catalyzedesterification of a retinol with a carboxylic acid, such as, aceticacid, propionic acid, butyric acid, valeric acid, caproic acid, caprylicacid, pelargonic acid, capric acid, lauric acid, oleic acid, stearaticacid, palmitic acid, myristic acid, linoleic acid, succinic acid,fumaric acid or the like. In another example, retinyl esters can beformed by reaction of an acyl halide with a retinol (Van Hooser et al.,Proc. Natl. Acad. Sci. USA, 97:8623-28 (2000)). Suitable acyl halidesinclude, for example, acetyl chloride, palmitoyl chloride, or the like.

In another embodiment of the invention, the synthetic retinal derivativeis a retinyl ester. Retinyl ethers can be formed by methods known in theart, such as for example, reaction of a retinol with a primary alkylhalide.

In another embodiment of the invention, trans-retinoids can beisomerized to cis-retinoids by exposure to UV light. For example,all-trans-retinal, all-trans-retinol, all-trans-retinyl ester orall-trans-retinoic acid can be isomerized to 9-cis-retinal,9-cis-retinol, 9-cis-retinyl ester or 9-cis-retinoic acid, respectively,by exposure to a UV light having a wavelength of about 365 nm, andsubstantially free of shorter wavelengths that cause degradation ofcis-retinoids, as further described herein.

In another embodiment of the invention, the synthetic retinal derivativeis a retinyl acetal or hemiacetal, which can be prepared, for example,by treatment of 9-cis- and 11-cis-retinals with alcohols in the presenceof acid catalysts. Water formed during reaction is removed, for exampleby Al2O3 of a molecular sieve.

In another embodiment of the invention, the synthetic retinalderivatives is a retinyl oxime, which can be prepared, for example, byreaction of a retinal with hydroxylamine, O-methyl- or O-ethylhydroxylamine, or the like.

The synthetic retinal derivative of the invention can be substantiallypure in that it contains less than about 5% or less than about 1%, orless than about 0.1%, of other retinoids. One or more synthetic retinalderivatives may be used in the therapeutic regimens of the invention.

Pharmaceutically Acceptable Compositions of the Invention

Synthetic retinal derivatives of the invention can be formulated, forexample, as pharmaceutically acceptable compositions for localadministration to the eye and/or for systemic administration such asintravenous, intramuscular, subcutaneous, enteral, parenteral or oraladministration.

Synthetic retinal derivatives of the invention can be formulated foradministration using pharmaceutically acceptable vehicles as well astechniques routinely used in the art. A vehicle can be selectedaccording to the solubility of the synthetic retinal derivative.Suitable pharmaceutically acceptable compositions include those that areadministrable locally to the eye, such as by eye drops, injection or thelike. In the case of eye drops, the formulation can also optionallyinclude, for example, ophthalmologically compatible agents such asisotonizing agents such as sodium chloride, concentrated glycerin, andthe like; buffering agents such as sodium phosphate, sodium acetate, andthe like; surfactants such as polyoxyethylene sorbitan mono-oleate (alsoreferred to as Polysorbate 80), polyoxyl stearate 40, polyoxyethylenehydrogenated castor oil, and the like; stabilization agents such assodium citrate, sodium edentate, and the like; preservatives such asbenzalkonium chloride, parabens, butylated hydroxyanisole (BHA) and thelike; and other ingredients. Preservatives can be employed, for example,at a level of from about 0.001 to about 1.0% weight/volume. The pH ofthe formulation is usually within the range acceptable to ophthalmologicformulations, such as within the range of about pH 4 to 8.

Synthetic retinal derivatives used in the therapeutic regimens of theinvention can be delivered to the eye by any suitable means, including,for example, oral, intravenous, intramuscular or local administration.Modes of local administration can include, for example, eye drops,intraocular injection or periocular injection, or delivery via acontrolled release drug delivery formulation and/or device. Periocularinjection typically involves injection of the synthetic retinalderivative into the conjunctiva or to the tenon (the fibrous tissueoverlying the eye). Intraocular injection typically involves injectionof the synthetic retinal derivative into the vitreous. Theadministration can be non-invasive, such as by eye drops or in oraldosage form.

In certain embodiments, the synthetic retinal derivative is formulatedinto a formulation suitable for oral or local delivery to the eyes. Mostof the synthetic retinal derivatives are oily substances and lipophilicand are therefore easily miscible with one or more lipid vehicles.

Certain synthetic retinal derivatives of the invention (e.g.,9-cis-retinyl esters) are light- and oxygen-sensitive. It is thereforedesirable to maintain the stability and maximize the efficacy andshelf-life of the formulation. A suitable lipid vehicle may be selectedbased on its ability to stabilize the 9-cis-retinyl esters suspended orsolubilized therein. As used herein, “lipid” or “lipid vehicle” refersto one or a blend of fatty acid esters. In various embodiments, thelipid vehicle comprises one or more triglycerides, which are formed whena single glycerol is esterified by three fatty acids. Triglyceridesinclude both vegetable oils and animal fats. In various embodiments, thelipid vehicle comprises more than 50 w/w % polyunsaturated fatty acids,the polyunsaturated fatty acids including an omega-6 fatty acid and anomega-3 fatty acid in a ratio (by weight) of less than 15.

In a preferred embodiment, the synthetic retinal derivative isformulated into an oral formulation comprising a 9-cis-retinyl ester anda lipid vehicle. In a further embodiment, the 9-cis-retinyl ester is9-cis-retinyl acetate, and the lipid vehicle is soy bean oil. Thedescription of additional lipid vehicles can be found in, for example,International Patent Application No. PCT/US2009/059126 in the name ofQLT Inc., the relevant disclosure of which is incorporated herein in itsentirety.

The present invention also provides kits that contain a syntheticretinal derivative of the invention or a pharmaceutically acceptablecomposition of the invention. The kit also includes instructions for theuse of the synthetic retinal derivative or the pharmaceuticallyacceptable composition in the therapeutic regimens and methods of theinvention. Preferably, a commercial package will contain one or moreunit doses of the synthetic retinal derivative or the pharmaceuticallyacceptable composition for use in a therapeutic regimen or method of theinvention. For example, such a unit dose may be an amount sufficient forthe preparation of an intraocular injection. Alternatively, such a unitdose may be an amount sufficient to effect treatment or amelioration ofa visual disorder when administered to a human subject. It will beevident to those of ordinary skill in the art that for those syntheticretinal derivatives of the invention or pharmaceutically acceptablecompositions of the invention which are light and/or air sensitive mayrequire special packaging and/or formulation. For example, packaging maybe used for the kit which is opaque to light, and/or sealed from contactwith ambient air, and/or formulated with suitable coatings orexcipients.

Dosage, Dosage Frequency and Modes of Administration

The synthetic retinal derivatives and pharmaceutically acceptablepharmaceutical compositions comprising the synthetic retinal derivativesused in the therapeutic regimens of the invention may be in the form ofan oral dose. In one embodiment, a pharmaceutically acceptablecomposition of the invention comprising a synthetic retinal derivativeand a lipid vehicle is administered orally to the subject in thetherapeutic regimen of the invention. In another embodiment of theinvention, the orally-administered pharmaceutically acceptablecomposition of the invention comprises a 9-cis-retinyl ester and soybeanoil. In another embodiment of the invention, the orally-administeredpharmaceutically acceptable composition comprises 9-cis-retinyl acetateor 9-cis-retinyl succinate and soybean oil (USP grade).

Oral administration of the synthetic retinal derivatives of theinvention has several potential advantages, including exposure of allphotoreceptors in both eyes of the subject undergoing the therapeuticregimen of the invention to therapy, lack of surgical intervention, andcessation of administration at any time. In a preferred embodiment,treatment may begin in subjects diagnosed with LCA just after birth andcontinue throughout the subject's life. In other embodiments,therapeutic regimens of the invention may be used in combination withvector-mediated gene transfer therapy for replacement of one or moregenes, for example, RPE65 or LRAT, associated with the visual cycle in asubject, for example in subjects who have already received gene therapyas a method for treating or ameliorating visual disorders associatedwith endogenous retinoid deficiency in a subject.

Additional suitable dosage forms for the synthetic retinal derivativesof the invention include those formulated for injection. For example, asynthetic retinal derivative for use in a therapeutic regimen of theinvention can be provided in an injection grade saline solution, in theform of an injectable liposome solution, or other carriers or vehicles.In certain embodiments, the synthetic retinal derivatives describedherein can be formulated for local injection into the eyes. Intraocularand periocular injections are known to those skilled in the art and aredescribed in numerous publications including, for example, OphthalmicSurgery: Principles of Practice, Ed., G. L. Spaeth, W. B. Sanders Co.,Philadelphia, Pa., U.S.A., pages 85-87 (1990). In other embodiments, thesynthetic retinal derivatives can be formulated for systemic deliveryvia subcutaneous injection. In one embodiment, for subcutaneousinjection, a 9-cis-retinyl ester may be formulated in a lipid vehicle,such as soybean oil.

A synthetic retinal derivative can also be administered in a therapeuticregimen of the invention in a time release formulation and/or device,for example in a composition which includes a slow release polymer, orvia a time-release, delayed release or sustained release delivery systemto afford delivery of a synthetic retinal derivative over the course ofone or more of the dosing phase time periods. Such systems can avoidrepeated administrations of compositions described in this disclosure.Numerous types of drug release delivery systems are known to those ofskill in the art, including ophthalmic drug delivery devices designedfor positioning in or near the ocular tissues, for example, suitable forplacement adjacent the sclera, or in the punctum, or within thevitreous, and capable of delivering one or more synthetic retinoids ofthe present invention on a time-released, or delayed release orsustained release fashion. The synthetic retinal derivative for use inthe therapeutic regimens of the invention can be prepared with acarrier(s) that will protect the compound against rapid release, such asa controlled release formulation, including implants andmicroencapsulated delivery systems. Biodegradable, biocompatiblepolymers can be used, such as ethylene vinyl acetate, polyanhydrides,polyglycolic acid, collagen, polyorthoesters, polylactic acid andpolylactic, polyglycolic copolymers (PLG). Many methods for thepreparation of such formulations are known to those skilled in the art.

The therapeutic regimens of the present invention produce meaningfulimprovement or recovery of vision that is long lasting, while reducingchronic toxic side effects can be greatly reduced, and thus in oneembodiment, the therapeutic regimens of the present invention may besuitable as a long-term (chronic) therapeutic regimen.

The length of the period of time between the first dosing period and thesubsequent dosing period may optionally be based on the persistence orincrease in one or more of the subject's visual function parameters, asdefined herein. Dosing-dependent effects or improvement in the subject'svisual functions may be observed and assessed on an individual basis toallow for customization of the subject's dosing requirements.Alternatively, commencement of any subsequent dosing period may be basedon a decrease in one or more of the subject's visual function parametersrelative to previous efficacy assessments during first dosing period andany resting period. For instance, the efficacy of the subject's dosingmay be assessed at, for example, about 1 month, 4 months, 6 months, 8months, 11 months following the first dosing period. At any point of theassessment, a subsequent dosing period may commenced based on regressionor a return to baseline of one or more of the subject's visual functionparameters during any resting period.

Evaluation of Therapeutic Effect

The effectiveness of the therapeutic regimens of the invention intreating or ameliorating visual disorders in a subject associated withan endogenous retinoid deficiency can be evaluated based on severalmeasures of vision function, including those as described below.

Improvements in the subject's visual functions in one or both eyes maybe evaluated based on measures of visual field, visual acuity, andretinal sensitivity testing, as well as electroretinograms, dynamicpupillary response, nystagmus, cortical visual function, color vision,visual mobility testing, and patient-reported outcomes of quality oflife/ability to perform life tasks. Improvements in the subject's visualfunctions in one or both eyes during a therapeutic regimen of theinvention can be demonstrated by comparing the subject's visualfunctions of each eye with a baseline measure of the subject's visualfunctions of each eye prior to the treatment by a therapeutic regimen ofthe invention or by comparing the subject's visual functions of each eyewith a comparable human visual system not receiving the treatment.

It was demonstrated (see Examples 2 and 3 below) that one or more of thevisual function parameters listed below improved rapidly in three LCApatients, all of which had genetic mutations in the LRAT gene. Theseimprovements, particularly in visual field and visual acuity, could besustained for up to 11 months following an initial dosing period of oneweek. Thus, it has been identified that, for subjects with endogenousretinoid deficiency, a population of dormant photoreceptors are capableof rapidly responding to external manipulation provided by thetherapeutic regimen of the invention described herein, i.e., by theadministration of a synthetic retinal derivative as disclosed herein.Efficacy is also observed in LCA subjects with mutations in the RPE65gene (Examples 4 and 5) as well as subjects with RP (Example 7 and 8).

1. Visual Field

The visual field is an individual's entire scope of vision, includingthe central and peripheral (side) vision of each eye. Normal humanvisual field extends to approximately 60 degrees nasally (toward thenose, or inward) in each eye, to 100 degrees temporally (away from thenose, or outwards), and approximately 60 degrees above and 75 below thehorizontal meridian.

Subjects having visual disorders as described herein may have variousdegrees of impairments that can span from non-detectable tosignificantly contracted visual field.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's visual field improves, temporally and/or nasally, in theinitial dosing period as compared to the baseline of the subject'svisual field obtained prior to the initial dosing period. In certainembodiments, the subject's visual field continues to improve during theresting period as compared to the improvement in the subject's visualfield during the initial dosing period. In certain embodiments, theimprovement in the subject's visual field observed during the initialdosing period is sustained during the resting period.

In various embodiments of the present invention, for example forsubjects with LRAT or RPE65 mutation, including without limitation, LCAor arRP patients, the subject's visual field expands by at least 5degrees or at least 10 degrees nasally, and at least 20 degrees, or atleast 30 degrees or at least 40 degrees temporally during the initialdosing period.

Commencement of the subsequent dosing period may begin upon assessmentof the improvement of the subject's visual field during the initialdosing period and during the resting period. For example, the subsequentdosing period may commence if the subject's visual field returns to alevel prior to the initial dosing period or to a pre-determined levelduring the initial resting period.

Visual field can be tested by art-recognized techniques and standards,such as Kinetic Perimetry by Goldmann Visual Field testing (GVF) orStatic Perimetry by Humphrey Visual Field Analyzer (HFA).

2. Visual Acuity

Visual acuity refers to acuteness or clearness of vision, especiallyform vision, which is dependent on the sharpness of the retinal focuswithin the eye and the sensitivity of the interpretative faculty of thebrain. Visual acuity is a measure of the spatial resolution of thevisual processing system and is usually tested in a manner to optimizeand standardize the conditions.

Visual acuity testing is the most common method for assessing asubject's visual function, and the Early Treatment Diabetic RetinopathyStudy (ETDRS) method is the gold-standard for measuring treatmenteffects in clinical trials. However, this method measures vision underhigh contrast and standard room lighting conditions. Subjects with LCAtypically have the most difficulty with vision under conditions of lowluminance. The Smith-Kettlewell Institute Low Luminance (SKILL) Chartwas designed to assess vision under conditions of low contrast thatsimulates low lighting, through a test performed with standard indoorlighting. The SKILL Chart has a high-contrast near-acuity chart on oneside (black letter on white), and a low-luminance, low-contrast chart onthe other (gray letters on a dark background). The low reflectance ofthe dark side of the card simulates testing in a dim environment.Repeatability of acuity testing with the SKILL card has been shown to beas good as repeatability of Snellen acuity.

In certain embodiments of the present invention, the degree ofimprovement in visual acuity over baseline may be dependent on thesubject's baseline visual acuity. For patients with very low visualacuity (light perception or hand waving, zero letters), clinicallymeaningful improvement may be associated with an improvement of 1-5ETDRS letters. Patients with higher baseline VA (20-50 letters) may havea higher potential improvement from baseline based on their overallretinal health and architecture.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's visual acuity improves during the initial dosing period ascompared to the subject's visual acuity level prior to the treatmentduring the initial dosing period, i.e, the subject's visual acuitybaseline. In certain embodiments, the subject's visual acuity continuesto improve during resting period as compared to the improvement in thesubject's visual acuity level observed at the end of the initial dosingperiod. In certain embodiments, the improvement in the subject's visualacuity is sustained during the resting period at about the subject'svisual acuity level at the end of the initial dosing period.

3. Retinal Sensitivity

A subject's retinal sensitivity can be measured by determining theabsolute intensity threshold, that is, the minimum luminance of a testspot required to produce a visual sensation. Retinal sensitivity isrelated to the eye's ability to adjust to various levels of darkness andlight and to detect contrast.

Full-field stimulus testing (FST) was developed to measure dark-adaptedsensitivity using commercial equipment in patients unable to fixate(Roman, A. J. et al., Physiol. Meas. 28(8):N51-N56 (2007)). The testuses a full-field (Ganzfeld) white-flash stimulus presentation availablein a commercial ERG dome (Diagnosys) and available software allows forreliable, efficient psycho-physical measures of absolute threshold,expressed in log luminance (log cd/m2). FST has previously been shown tomeasure rod and cone sensitivity to white, blue, and red stimuli inRPE65-deficient LCA patients who had limited or no ERG responses(Jacobson, S. G. et al., Invest Ophthalmol Vis Sci. 50(5):2368-2375(2009)). Therefore, FST is a useful test to measure visual function insubjects having visual disorders associated with endogenous retinoiddeficiency, including LCA or RP patients, or subjects having LRAT orRPE65 mutation.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's retinal sensitivity improves during the initial dosingperiod as compared to the subject's retinal sensitivity baseline priorto the treatment during the initial dosing period. In certainembodiments, the subject's retinal sensitivity continues to improveduring the resting period as compared to the improvement in thesubject's retinal sensitivity at the end of the initial dosing period.In certain embodiments, the improvement in the subject's retinalsensitivity is sustained during the resting period at about thesubject's retinal sensitivity level at the end of the initial dosingperiod.

4. Electroretinograms (ERG)

ERG testing is a well-accepted standard test and is used routinely todiagnose and monitor progression of most inherited retinal diseases(IRD) including LCA. Physicians specializing in IRD agree thatsignificant, repeatable improvements in ERG responses are indicative ofimproved visual function.

The three main types of traditional global or full-field ERG thatevaluate general retinal response are scotopic, photopic, and flickertesting. A limitation of full-field ERG is that the recording is amassed potential from the whole retina. Unless 20% or more of the retinais affected with a diseased state, ERG recordings are usually normal(e.g., a legally blind person with macular degeneration, enlarged blindspot or other central scotomas may have normal global ERGs). Most LCAand RP subjects have virtually no measurable ERG recordings, yet many ofthese subjects can still see, some quite well. Recent gene therapytrials for LCA have not reported changes in full-field ERG results,which may be because the methods in these trials treated less than 10%of the retina, so the ERG results would not be expected to change.

5. Dynamic Pupillary Response (Pupillometry)

Pupillary responses (constriction of the pupil in response to a brightlight stimulus) may be abnormal in subjects having a visual disorder asdescribed herein. Dynamic pupillometry is a non-invasive method torecord the pupillary response and monitor potential changes in responseto treatment. Pupillary reflexes improved in LCA subjects with RPE65deficiency after receiving gene therapy (Maguire, A. M. et al., New EnglJ Med. 358:2240-2248 (2008)). This procedure may be performed with anappropriate pupillometer.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's pupillary response improves during the initial dosingperiod as compared to the subject's pupillary response baseline levelprior to the treatment during the initial dosing period. In certainembodiments, the subject's pupillary response continues to improveduring the resting period as compared to the subject's pupillaryresponse level at the end of the initial dosing period. In certainembodiments, the improvement in the subject's pupillary response issustained during the resting period at about the subject's pupillaryresponse level at the end of the initial dosing period.

6. Nystagmus

Nystagmus is a form of involuntary eye movement that is frequentlyassociated with visual impairment, including LCA. Nystagmus amplitudeand frequency is measured non-invasively and can be used to monitorpotential changes in response to treatment such as by videotaping theeye movements for qualitative clinical analysis of the subject'soscillation and strabismus. (Maguire, A. M. et al., New Engl J Med.358:2240-2248 (2008)).

Thus, in one embodiment of the therapeutic regimens of the invention,the subject demonstrates a decrease in the amplitude and/or frequency ofnystagmus during the initial dosing period. In another embodiment, thesubject demonstrates a continued decrease in the amplitude and/orfrequency of nystagmus during the resting period.

7. Cortical Visual Function

The therapeutic effectiveness of the therapeutic regimens of theinvention may be monitored using effects of the subject's vision oncortical visual function as measured by functional magnetic resonanceimaging (fMRI). Functional scans consist of a contrast sensitivitychallenge, movement stimulus challenge, and higher level cognitivechallenges. Data are normally displayed as percentage change in MRIsignal from baseline. Maps of statistical significance will be displayedon the reconstructed cortical surface from each individual. The pre- andpost-treatment scans will be directly compared in terms of the extentand magnitude of activation.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's cortical vision function improves during the initialdosing period as compared to the subject's cortical vision functionbaseline level prior to the treatment during the initial dosing period.In certain embodiments, the subject's cortical vision function continuesto improve during the resting period as compared to the subject'scortical vision function level at the end of the initial dosing period.In certain embodiments, the improvement in the subject's cortical visionfunction is sustained during the resting period at about the subject'scortical vision function level at the end of the initial dosing period.

8. Color Vision

A color vision test checks a subject's ability to distinguish betweendifferent colors. Ishihara plates are used to detect, classify andestimate the degree of defect in color vision. Color vision testing isalso used to evaluate the function of the optic nerve and hereditaryretinal disease.

Color vision may be assessed by methods known in the art, including theIshihara Color Test. The test consists of a number of colored plates,each of which contain a circle of dots appearing randomized in color andsize. Within the pattern are dots which form a number visible to thosewith normal color vision.

Thus, in one embodiment of the therapeutic regimens of the invention,the subject's color vision improves during the initial dosing period ascompared to the subject's color vision baseline level prior to thetreatment during the initial dosing period. In certain embodiments, thesubject's color vision continues to improve during resting period ascompared to the subject's color vision level at the end of the initialdosing period. In certain embodiments, the improvement in the subject'scolor vision is sustained during the resting period at about thesubject's color vision level at the end of the initial dosing period.

9. Dark Adaptation

Dark adaptation is defined as the recovery of light sensitivity by theretina in the dark after exposure to a bright light. Methods to measuredark adaptation are known in the art, including those methods defined inU.S. Pat. No. 7,494,222 and U.S. Pat. No. 7,798,646, the contents ofwhich are herein incorporated by reference.

10. Visual Mobility

Visual mobility may be used as a measure of improved retinal function.Improvements in visual mobility can be determined by methods known inthe art, including standardized obstacle courses and mazes, includingthose described in Bainbridge et al. N Engl J Med. 358:2231-9 (2008) andMaguire, A. M. et al., New Engl J Med. 358:2240-2248 (2008). Subjectsmay be assessed based on the time to navigate the course, or based onthe number of times a subject bumps into obstacles or walks off coursecompared to the total number of obstacles present.

11. Visual Function Questionnaires

There are a number of known Visual Function Questionnaires (VFQ's) whichmay be used to assess improvement in a subject's visual function. Onesuch questionnaire is the Children's Visual Function Questionnaire(CVFQ) (see, e.g., Birch, E. E. et al., J. AAPOS. 11:473-9 (2007)). Thisis a vision-specific quality-of-life instrument designed for use withparents of infants and young children.

Another questionnaire is the Low Luminance Questionnaire (LLQ). This isa questionnaire that has been developed specifically to assess visualperformance of adults in low lighting conditions, such as night-time ordarkened rooms (see, e.g., Owsley, C. et al., Invest Ophthalmol Vis Sci47:528-535 (2006). This questionnaire was validated in a population ofolder subjects similar to the population eligible for the clinical studydescribed below and correlates to rod-mediated parameters of darkadaptation.

The use of the VFQ's assists in identifying subjective improvements invisual function, particularly with respect to activities of daily lifefollowing administration of a compound of the invention by thetherapeutic regimens described herein.

12. Spectral Domain-Optical Coherence Tomography

Optical coherence tomography (OCT)/autofluorescence (FAF) machines, suchas the Heidelberg Spectralis (Heidelberg Engineering, Germany), may beused to conduct ocular tomography scans. The analyses of the scans mayprovide information as to the overall retinal health, includingvisualization of the photoreceptor layer, the outer segments, andmeasurement of retinal thickness and to assess presence or absence ofautofluorescence.

The following examples are provided merely as illustrative of variousaspects of the invention and shall not be construed to limit theinvention in any way.

EXAMPLES Example 1 Safety Study

A study of an orally-delivered pharmaceutically acceptable compositionof the invention was conducted in twenty (20) healthy human volunteersto determine the safety of a composition comprising 9-cis-retinylacetate ((2E, 4E, 6Z,8E)-3,7-dimethyl-9-(2,6,6-trimethylcyclohex-1-en-1-yl)nona-2,4,6,8-tetraen-1-yl acetate) and butylated hydroxyanisole (BHA) dissolved insoybean oil (USP). The concentration of 9-cis-retinyl acetate in thecomposition was adjusted such that the volume to be administered wasconvenient. For the dosing range of the study, compositions of 1.25mg/mL, 5.0 mg/mL and 20 mg/mL 9-cis-retinyl acetate were prepared,containing 0.10% w/w BHA in Soybean oil (USP). Six cohorts of subjectsreceived escalating doses of the Composition orally from 1.25 mg/m2 upto 40 mg/m2. The composition was found to be well tolerated and therewere no serious adverse events after 7 days of monitored therapy in aPhase I testing center. The most frequently reported side effects wereheadache (6 subjects, 12 events), facial flushing (2 subjects, 7events), and a facial burning sensation (2 subjects, 6 events), whichwere primarily reported from the 40 mg/m2 dose group and collectivelyaccounted for 25 of the 43 (58%) adverse events (AE) reported. In total,41 of 43 AEs were of mild intensity. In some subjects, there was amodest and reversible elevation in triglycerides across all doses and amodest and reversible decline in high density lipoproteins (HDL) at the10-40 mg/m2 doses.

Example 2 Efficacy Study for LCA Subjects

A study was designed to determine the efficacy of the composition ofExample 1 orally administered to human subjects having LCA (caused bymutations of either LRAT or RPE65). Subjects received a once-dailyloading dose of the composition orally (40 mg/m2) for 7 days. Subjectswere treated on an outpatient basis, but they received study treatmentin the research clinic under medical supervision for each day oftreatment. During the study, subjects were required to limit vigorousphysical activity (to avoid laboratory variability) and avoid excessivevitamin A intake in order to reduce the influence of such factors on theassessment of safety variables in this study.

Both eyes of each subject were evaluated separately. Protocol-definedassessments of visual function included: best-corrected visual acuitytesting using Early Treatment Diabetic Retinopathy Study (ETDRS) testingfollowed by low/high contrast Smith-Kettlewell Institute Low Luminance(SKILL) charts; visual field testing using Goldmann perimetry;full-field electroretinogram (ERG); and full-field stimulus thresholdtesting (FST). Baseline ERGs, ETDRS, and SKILL tests were repeatedtwice. During and after treatment, visual function tests were conductedon Day 1, 7, 9/10, and 14/15.

It was at first believed that maximal effects of the composition wouldbe achieved by limiting the amount of light reaching the retina and thusavoiding loss of the active chromophore, 9-cis-retinal, by bleaching.Therefore, in the first 2 subjects, an eye patch was worn on the eyewith worse vision at all times until Day 7, except when undergoing theprotocol-defined vision assessments. Surprisingly and unexpectedly,bleaching was not observed and the improvement in visual functionpersisted or continued to improve after Day 7. Consequently, after datafrom the first 2 subjects did not reveal any difference between thepatched and unpatched eye, the requirement of an eye patch was removedfrom the protocol.

The efficacy assessments of this study for three subjects are set forthin Example 3 to 5 below.

Example 3 Efficacy Assessments

Both eyes of each subject were evaluated as described in Example 2.Protocol-defined assessments of vision were performed from the first dayof dosing on Day 0 until Day 6. Follow-up visits were conducted until atleast Day 13. If a clinical benefit was detected at Day 13, additional,optional follow-up visits were scheduled at biweekly intervals, withbiweekly telephone calls between clinic visits, to continue assessingthe status and duration of beneficial effects until a return to baselinewas noted.

Subject #1 was followed for over 100 days, while Subject #2 was followedfor over 75 days.

Early Treatment in Diabetic Retinopathy Study (ETDRS) best-correctedvisual acuities were measured for each subject at 1 meter and 4 meters.Smith-Kettlewell Institute Low Luminance (SKILL) acuities, Ishiharacolor plates, Goldmann visual fields (with V4e and We targets, GVF),ISCEV standard cone and rod electroretinogram (ERG) parameters,including rod, mixed rod/cone, 30 Hz flicker and cone mediated ERGs(Diagnosys, LLC) were also measured. Full-field stimulus testing (FST)(Diagnosys, LLC) according to a published protocol was performed.Finally, in vivo retinal microscopy was performed by optical coherencetomography (OCT) and fundus autofluorescence was ascertained bySpectralis (Heidelberg Engineering). Efficacy was measured by comparingthe results of pretreatment objective and subjective visual functiontesting with results of the same parameters obtained during and afterthe oral administration of the composition of Example 1.

Vision Characteristics of Subject #1 Before and After Treatment

Subject #1 is a 10-year-old Caucasian female with LCA. At baseline, shewas legally blind and presented with lifelong night blindness, visualloss, nystagmus, and severely attenuated ERGs. Her Goldmann VisualFields (GVFs) had progressively deteriorated. Her Early Treatment inDiabetic Retinopathy Study (ETDRS) visual acuity was 36 letters OD and26 letters OS (approximately 20/200 and 20/320 Snellen equivalent).There was mild horizontal nystagmus. Ophthalmoscopic examinations werenormal except for the “salt and pepper” changes in the retinal pigmentepithelium (RPE) of the peripheral retina. Her GVF was constricted inboth eyes to 30° with the V4e target and she was unable to see the I4etarget (FIG. 2). She had no detectable rod-mediated or rod/cone-mediatedERGs, but some measurable cone-mediated activity (3.5 μV b-wave). Twobaseline full-field threshold sensitivity (FST) tests revealed averagethresholds of 0.5206 log cd/m2 (OD), whereas optical computed tomography(OCT) documented an essentially normal retinal structure.

Within 12 hours after the first dose of the Composition, the subjectdeveloped a moderate headache and experienced 1 episode of vomiting,followed by photophobia. The headache resolved a few hours later and thesubject and her family reported improved visual function, especially ina dimly lit environment. These subjective improvements were reported tohave persisted at 4 months after cessation of dosing with thecomposition.

During the study, there were no changes in the ophthalmoscopic exam.GVFs changed significantly and consistently (FIG. 2A-G). On Day 7, a newlarge temporal crescent was documented in both eyes by using the V4etarget that remained on Day 14, when it was documented that she was alsoable to see the I4e (smaller) target (FIG. 2C). On Day 30, the visualfields had expanded temporally from 30° to 70° and nasally from 30° to40° (FIG. 2D). The most unexpected change was found 4 monthspost-dosing, when her GVF size by the V4e target appeared close to thesize expected in a normally-sighted child (FIG. 2E). FST sensitivitythresholds improved in the OD to 0.0990 log cd/m2 on Day 2 (24 hoursafter the first dose) and remained at 0.1496 log cd/m2 on Days 8, 10 and15 (lower thresholds signify greater retinal sensitivity). ERGmeasurements, color vision and Smith-Kettlewell Institute Low Luminance(SKILL) chart measurements were unchanged from baseline.

ETDRS acuities improved during treatment, and has been monitored untilMonth 14 (FIG. 4A). Continued assessments showed that the improvementsrelative to baseline (screening) have been maintained beyond the end ofthe treatment period.

Vision Characteristics of Subject #2 Before and After Treatment

Subject #2 is the 12-year-old brother of subject #1, who was alsodiagnosed with LCA at birth. He has had lifelong night blindness,nystagmus, and is legally blind. ETDRS best-corrected visual acuity was9 letters OD and 7 letters OS (approximate Snellen 20/800) at baseline.Ophthalmoscopic examination revealed arteriolar narrowing, significantperipheral pigmentary degeneration and a prominent maculopathy withfoveal atrophy and RPE disruption. GVFs showed a large central defectwith relatively intact peripheral fields. His ERGs were non-detectable.Macular OCT revealed abnormalities in the retinal architecture withdeposits between the photoreceptor and outer plexiform layers.

Upon treatment with the Composition of Example 1, this subject did notdevelop a headache. There was no change in the ophthalmoscopic exam.FIG. 4B shows that the ETDRS best-corrected visual acuities weresignificantly improved following treatment. This improvement has beenmaintained during follow-up (79 days). There were no changes in GVF,color vision, SKILL, ERG, or FST findings.

Vision Characteristics of Subject #3 Before and After Treatment

Subject #3 is a 38-year-old woman with LCA unrelated to the first 2subjects. She had legal blindness, nystagmus, and required assistance toambulate. She was unable to see any letters on the ETDRS chart. Shecould see “hand motions” without the ability to count fingers at 1 m.Similarly, her color vision and SKILL visual acuity scores were 0. HerGVF was non-detectable (FIG. 3A) and ERG was significantly attenuated OD(1.2 μv) and not recordable OS. The OCT examination revealed an intactretinal architecture with a visible foveal OS/IS junction, confirmingthe presence of foveal photoreceptors.

Twelve hours after the first dose of the Compostion, she developed amoderate headache and photophobia. The headache resolved a few hourslater and her photophobia decreased over the next 2 days. On Day 2 oftreatment, while in the clinic, she reported that she was clearly ableto see the outline of a computer monitor, the mirror in the bathroom anda white sheet of paper on a dark desk, none of which she had been ableto see prior to the study. There were no changes in the ophthalmoscopicexam. On Day 9, she was able to read the ETDRS chart for the first time,and reached a letter score of 2 OS (approximate Snellen 20/1000). Shewas also able to reliably see the V4e target centrally on the GVF (FIG.3B) on Days 3 and 7, but this became less reliable on Days 9 and 14.Retinal sensitivity improved from 1.1966 at screening to 0.9508 logcd/m2 at Day 14 OD and from 2.2763 to 2.0688 log cd/m2 OS. Her othervisual function tests were unchanged from baseline.

Summary of Results with Subjects #1, 2 and 3

Three subjects aged 10, 12, and 38 years, all of whom have a geneticmutation in LRAT, were enrolled and treated. All 3 patients had theidentical homozygous c.217_(—)218delAT deletion in LRAT that leads to ap. Met73AspfsX47 frameshift and premature truncation of the LRATprotein, which likely represents a null allele. After 7 days oftreatment with the oral composition of Example 1, all of the subjectsexperienced clinically meaningful improvements in one or more visualfunction parameters, including best-corrected visual acuity, Goldmannvisual field, and/or retinal sensitivity as measured by full-fieldsensitivity threshold testing. Subjects have also reported meaningfulimprovements in their visual performance related to tasks of dailyliving. The onset of visual changes was rapid and there was progressiveimprovement beyond the 7 days of treatment, with some effects persistingfor more than 4 months after treatment was completed. Improvements weremost pronounced in the youngest subject, but clinically relevant changeswere also noted in the one adult subject treated to date. The studytreatment has been well-tolerated, with mild to moderate adverse eventsobserved including transient headache, photophobia, and an increase intriglyceride levels.

Discussion

In the above example, 7 days of treatment with the Compositionmeaningfully restored bilateral visual function in 3 subjects with LCAand LRAT mutations, who had lifelong progressive visual loss due to thissevere and blinding retinal condition. Improvement in three visualfunction parameters, including ETDRS visual acuities, GVF size andretinal sensitivity by FST, have been documented. Improvements becameevident in as little as 12 hours following the first oral dose of theComposition and persisted or increased in magnitude in all follow-upvisits to date (subject #1 over 14 months, subject #2 over 3 months, andsubject #3 over 2 weeks).

ETDRS visual acuity improved in all 3 subjects and the GVF improved insubjects #1 and #3. FST testing documented improved retinalsensitivities in subject #1 and #3. In subject #1 the threshold improvedfrom 0.5206 to 0.0990 and then to 0.1496 log cd/m2. This improvement islikely significant as test-retest variability was measured at 0.3 logcd/m2 by Klein and Birch in similar patients with severe retinaldystrophies. Klein M, et al. Doc Ophthalmol 119:217-24 (2009). Theimprovement in retinal sensitivity in subject #3 does not reachsignificance. Subjects' improvements were not limited to clinicaltesting: all 3 have noted significant gains in their ability to read andperform activities of daily living. Most significantly, subject #1reported during the study that they no longer need a cane to navigate,sees in dimly lit areas, can read the clock on the wall and is now ableto perform her own self-care. Subject #3 was able during the study toread effectively by using vision aids and could see formed objects thatshe had not been able to see for years, including papers and mirrors.

Following oral administration of the composition, without wishing to bebound by any particular theory, it is believed that the drug isincorporated into lipid droplets in the liver and in the RPE (calledretinosomes) from which it is mobilized. Imanishi Y. et al. J Cell Biol166:447-53 (2004). It is secreted by the liver bound to retinolbinding-protein 4 (RBP4) and delivered to peripheral tissues, whereas inthe eye it is oxidized to 9-cis-retinal which feeds back into theretinoid cycle (FIG. 1). Moise A. R. et al. Biochemistry 46:4449-58(2007). Retinols, regardless of their isomeric form, are also stored inadipocytes and mobilized as needed into the circulation. O'Byrne S. M.et al. J Biol Chem 280:35647-57(2005). Thus, the long-term effects ofthis chromophore analog may derive from the fact that active drug isslowly released from adipocytes in the periphery.

Results observed in this study suggested the existence of dormantphotoreceptors that may rapidly respond to oral treatment such thatpatients at least into the fourth decade of life may benefit.Additionally, the findings in subject #1 suggested that the Compositionmay be able to restore visual function to large areas of previouslyunresponsive photoreceptors.has been maintained until Day 114 (FIG. 4A).Continued assessments showed that the improvements relative to baseline(screening) persisted for up to and including 11 months beyond the endof the treatment period.

Example 4 Efficacy Assessment

Subject #5 was a 13-year-old Asian female with LCA due to missensemutations in the RPE65 gene at Leu67Arg/Tyr368Cys. At baseline, herretinal architecture was relatively intact (OCT) and there was a smallamount of FAF in her inferior retina. At baseline, she presented withmild progression visual loss, nystagmus, non-detectable rod ERG, andseverely decreased cone ERG. Her Goldmann Visual Fields (GVFs) hadsuperior defects. Her Early Treatment in Diabetic Retinopathy Study(ETDRS) visual acuity was 31 letters OD and 34 letters OS (approximately20/250 Snellen equivalent).

The subject was treated with 40 mg/m2 of the Composition of Example 1for 7 days as described in Example 2. On Day 9, her binocular visualacuity was 20/30. The patient was monitored for 6 months post dosing.ETDRS acuities remain improved, at 67 letters OD and 62 letters OS (FIG.5). GVF improvements of the superior field and central field as observedwith IV4e and I4e targets also persisted. No change in ERG was observed.

The subject also reported meaningful improvements in activities of dailyliving after treatment. She noted the ability to see images on a smallscreen, see the colors of fireworks, and see stars in the sky. Shereported improved vision and mobility in dim light. The observedimprovements from baseline have been monitored for 6 months post dosingand have persisted during this time period.

Example 5 Efficacy Assessment

Subject #9 was a 14-year-old Hispanic female with LCA due to missensemutations in the RPE65 gene at Arg91Gln/Leu341Ser. At baseline, retinaldegeneration was observed by retinal exam and OCT, with relativelyintact foveal architecture (OCT) and FAF showed lipofuscin in theinferior retina. At baseline, she presented with mild nystagmus. HerEarly Treatment in Diabetic Retinopathy Study (ETDRS) visual acuity was41 letters OD and 47 letters OS (approximately 20/200 Snellenequivalent).

The subject was treated as outlined in Example 2, however a low dose, 10mg/m2 of the Composition of Example 1 for 7 days was used. There weresmall improvements in GVF, with her VF almost doubling as observed withthe I4e target (OD) by Day 14. ETDRS visual acuity improvements wereobserved, with the highest improvement from baseline of 10 letters (OD)at Day 14. Objective testing of cortical visual function before andafter drug treatment was conducted using fMRI, and marked improvementsobserved, with subjective reporting of the ability to see the images onthe fMRI projector post treatment.

The subject has also reported meaningful improvements in activities ofdaily living. Improvements in color vision, peripheral vision and visionin low lighting (night) were reported. The patient has been monitored 2months beyond the end of the treatment period and the observedimprovements from baseline persisted.

Example 6 Efficacy Assessment

The efficacy of the composition of Example 1 was tested in humansubjects having RP (with LRAT or RPE65 mutation). Subjects of a firstdose group received a once-daily initial dose of the Composition (40mg/m2) for 7 days. Subjects of a second dose group received a once-dailyinitial dose of the Composition (10 mg/m2) for 7 days. Subjects weretreated on an outpatient basis, but received study treatment in theresearch clinic under medical supervision for each day of treatment.During the study, subjects were required to limit vigorous physicalactivity (to avoid laboratory variability) and avoid excessive vitamin Aintake in order to reduce the influence of such factors on theassessment of safety variables in this study.

Both eyes of each subject were evaluated separately. Protocol-definedassessments of visual function included: best-corrected visual acuitytesting using Early Treatment Diabetic Retinopathy Study (ETDRS) testingfollowed by low/high contrast Smith-Kettlewell Institute Low Luminance(SKILL) charts; visual field testing using Goldmann perimetry;full-field electroretinogram (ERG); and full-field stimulus thresholdtesting (FST). Baseline ERGs, ETDRS, and SKILL tests were repeatedtwice. During and after treatment, visual function tests were conductedon Day 1, 7, 9/10, and 14/15.

There was no requirement that the subjects wear eye patch on one or botheyes.

The efficacy assessments of this study were conducted according to theprocedures as set forth in Examples 2 and 3, as well as assessments ofdynamic pupillary response, nystagmus, cortical visual function, visualmobility, and patient-reported outcomes on quality of life.

Subject #10 was a 27-year-old Indian male with RP due to homozygousmutations in the LRAT gene at c.525T>A; p.Ser175Arg. His ETDRS visualacuity at baseline was 71 letters OD and 60 letters OS (approximately20/40 and 20/62.5 Snellen equivalent) unaided.

The subject was treated with 40 mg/m2 of Composition A for 7 days, asdescribed in Example 6. Small improvements in ETDRS visual acuity wereobserved, with the highest improvement from baseline of 11.5 letters(OD) at Day 9, and 14.5 letters OS at Month 1.5. Large improvements inGVF OD were detected, and supported by subjective reports ofimprovements in peripheral vision. Objective testing of cortical visualfunction before and after drug treatment was tested using fMRI, withmarked improvements observed. No changes in cone or rod ERG were seen.

The subject reported meaningful improvements in activities of dailyliving. Sensitivity to daylight and fluorescent lights was noted. Darkadaptation times were also improved. The patient was monitored for 1.5months beyond the end of the treatment period, with improvements frombaseline persisting.

Summary of Efficacy Data

The following summarizes the results of the efficacy data from the aboveExamples.

A total of 11 subjects were studied, comprising two mutation types (LRATand RPE65), two disease types (Leber Congenital Amaurosis (LCA) andRetinitis Pigmentosa (RP)), different age ranges (6 subjects 6-15 yearsand 5 subjects 21-41 years), and a broad range of baseline visualfunction (FIG. 6). Four distinct ranges of baseline VA were established:hand motion and light perception, VA in the 0-20 letter range, VA in the20-50 letter range, and VA in the 50-70 letter range. Largest responsesin improvement in VA was observed for patients with a modest level ofretinal function (Vas in the 20-40 letter range), all of which weretreated with 40 mg/m2 of the Composition (FIG. 7). The best responses, 3lines of improvement, were seen in the younger patients (10-13 years).Relative improvements in visual acuity over baseline for the 11 subjectswere monitored for up to 14 months post dosing, demonstratingpersistence of clinically meaningful improvements (FIG. 8).

AMA low vision grid analyses of the GVFs from Day 14 for the first 9patients treated showed that 7 of 9 patients demonstrated markedimprovements as detected with either the smaller I4e target (FIG. 9A) orthe larger V4e target (FIG. 9B).

Preliminary data obtained from use of the Children's Visual FunctionQuestionnaire (CVFQ) or Low Luminance Questionnaire (LLQ) have beencombined with subjective reports on improvements in activities of dailyliving, and support the rapid improvement in visual function andprolonged therapeutic benefit of treatment with the Composition.

The study treatment was well tolerated. Adverse events related totreatment included transient photophobia and headaches, vomiting,moderate elevations in triglyceride levels, and a trend toward adecrease in HDL levels in all subjects. Effects on lipid metabolism, arecognize class effect for retinoids, was found to peak at Day 7 ofdosing (FIG. 10), but returned to baseline within 4 weeks aftertreatment was completed. Overall, adverse events, including effects onlipid metabolism, were more pronounced in the 40 mg/m2 group relative tothe lower dosed 10 mg/m2 group.

The previous examples are provided to illustrate but not to limit thescope of the claimed inventions. Other variants of the inventions willbe readily apparent to those of ordinary skill in the art andencompassed by the appended claims. All publications, patents, patentapplications and other references cited herein are hereby incorporatedby reference.

What is claimed is:
 1. A method for treating a human patient sufferingfrom the loss or impairment of vision caused by Leber CongenitalAmaurosis (LCA), wherein said patient is deficient in endogenous11-cis-retinal disorder, comprising the steps of: a) administering tothe human patient an initial therapeutically effective dose of asynthetic retinal derivative selected from the group consisting of9-cis-retinyl acetate, 9-cis-retinyl formate, 9-cis-retinyl succinate,9-cis-retinyl citrate, 9-cis-retinyl ketoglutarate, 9-cis-retinylfumarate, 9-cis-retinyl malate, 9-cis-retinyl oxaloacetate,9-cis-retinyl propionate, 9-cis-retinyl butyrate, 9-cis-retinylvalerate, 9-cis-retinyl hexanoate, 9-cis-retinyl heptanoate,9-cis-retinyl octanoate, 9-cis-retinyl nonanoate, 9-cis-retinyldecanoate, 9-cis-retinyl undecanoate, 9-cis-retinyl dodecanoate,9-cis-retinyl oxalate, 9-cis-retinyl malonate, 9-cis-retinyl glutarate,9-cis-retinyl adipate, 9-cis-retinyl pimelate, 9-cis-retinyl suberate,9-cis-retinyl azelate, and 9-cis-retinyl sebacate, b) refraining fromadministering to the human patient an additional therapeuticallyeffective dose of the synthetic retinal derivative for a restinginterval, wherein the resting interval is a time period between 1 monthand 14 months, c) administering to the human patient the additionaltherapeutically effective dose of the synthetic retinal derivative. 2.The method of claim 1, wherein the initial dose is administered in asingle dose.
 3. The method of claim 1, wherein the initial dose isadministered in a divided dose over a period of from 5 to 14 days. 4.The method of claim 1, wherein the initial dose is administered in adivided dose over a period of 7 to 10 days.
 5. The method of claim 1,wherein the initial dose is administered in a divided dose over a periodof one week.
 6. The method of claim 1, wherein the synthetic retinalderivative is 9-cis-retinyl acetate.
 7. The method of claim 6, whereinthe initial dose is administered in a divided dose over a period of twoweeks.
 8. The method of claim 1, wherein the initial dose is in therange of from 70 mg/m² to 525 mg/m².
 9. The method of claim 1, whereinthe initial dose is in the range of from 70 mg/m² to 490 mg/m².
 10. Themethod of claim 1, wherein the initial dose is in the range of from 280mg/m² to 490 mg/m².
 11. The method of claim 1, wherein the initial doseis in the range of from 70 mg/m² to 280 mg/m².
 12. The method of claim5, wherein the initial dose is 280 mg/m².
 13. The method of claim 8,wherein the initial dose of a synthetic retinal derivative isadministered orally.
 14. The method of claim 8, wherein the initial doseof a synthetic retinal derivative is administered by intraocularinjection.
 15. The method of claim 1, wherein the resting interval is atime period between 3 months and 14 months.
 16. The method of claim 15,wherein the resting interval is a time period between 6 months and 14months.
 17. The method of claim 15, wherein the resting interval is atime period between 9 months and 14 months.
 18. The method of claim 15,wherein the resting interval is a time period between 3 and 6 months.19. The method of claim 15, wherein the resting interval is a timeperiod between 6 and 9 months.
 20. The method of claim 15, wherein theresting interval is a time period between 3 and 9 months.
 21. The methodof claim 15, wherein the resting interval is a time period between 3months and 1 year.
 22. The method of claim 1, wherein the LCA is causedby a mutation in the LRAT gene.
 23. The method of claim 1, wherein theLCA is caused by a mutation in the RPE65 gene.
 24. A method for treatinga human patient suffering from loss or impairment of vision due toinherited mutations in RPE65 or LRAT genes associated with Lebercongenital amaurosis, comprising the steps of: a) administering to thehuman patient an initial therapeutically effective dose of 9-cis-retinylacetate, b) refraining from administering to the human patient anadditional therapeutically effective dose of the 9-cis-retinyl acetatefor a resting interval, wherein the resting interval is a time periodbetween 1 month and 14 months, and c) administering to the human patientthe additional therapeutically effective dose of the 9-cis-retinylacetate.
 25. The method of claim 24, wherein the initial dose isadministered in a divided dose over a period of from 5 to 14 days. 26.The method of claim 24, wherein the initial dose is in the range of from70 mg/m² to 525 mg/m².
 27. The method of claim 24, wherein the restinginterval is a time period between 3 months and 14 months.
 28. The methodof claim 1, wherein the resting interval is a time period between 1month and 2 months.
 29. The method of claim 1, wherein the restinginterval is a time period between 1 month and 3 months.
 30. The methodof claim 1, wherein the resting interval is a time period between 1month and 6 months.
 31. The method of claim 1, wherein the restinginterval is a time period between 1 month and 9 months.
 32. The methodof claim 1, wherein the resting interval is a time period between 1month and 1 year.
 33. The method of claim 24, wherein the restinginterval is a time period between 1 month and 2 months.
 34. The methodof claim 24, wherein the resting interval is a time period between 1month and 3 months.
 35. The method of claim 24, wherein the restinginterval is a time period between 1 month and 6 months.
 36. The methodof claim 24, wherein the resting interval is a time period between 1month and 9 months.
 37. The method of claim 24, wherein the restinginterval is a time period between 1 month and 1 year.
 38. The method ofclaim 24, wherein the resting interval is a time period between 6 monthsand 14 months.
 39. The method of claim 24, wherein the resting intervalis a time period between 9 months and 14 months.
 40. The method of claim24, wherein the resting interval is a time period between 3 months and 6months.
 41. The method of claim 24, wherein the resting interval is atime period between 6 months and 9 months.
 42. The method of claim 24,wherein the resting interval is a time period between 3 months and 9months.
 43. The method of claim 24, wherein the resting interval is atime period between 3 months and 1 year.
 44. The method of claim 1,wherein the initial dose is in the range of from 49 mg/m² to 840 mg/m².45. The method of claim 44, wherein the initial dose is in the range offrom 49 mg/m² to 280 mg/m².
 46. The method of claim 24, wherein theinitial dose is in the range of from 49 mg/m² to 840 mg/m².
 47. Themethod of claim 46, wherein the initial dose is in the range of from 49mg/m² to 280 mg/m².